COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX641 29772 
RC532  .F83  1913  Psychopathology  of  l 


^^    tm    f^ 


ilMLTH 
»0IimtKS 

MRumy 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/psychopathologyoOOfoxc 


Psychopathology 
of  Hysteria 


CHARLES    D.    FOX,    M.  D. 


fj& 


y^fi^^fr^ 


RICHARD   G.   BADGER 

THE  GORHAM  PRESS 
BOSTON 


COPYRIGHT  I913    BY   RICHARD   G.    BADGER 


All  Rights  Reserved 


c^ 


THE   GORHAM   PRESS,   BOSTON,   U.  S.  A. 


PREFACE 

Than  hysteria,  probably  there  is  not  any  dis- 
ease which  is  more  interesting,  which  has  been 
more  misunderstood,  which  is  capable  of  caus- 
ing a  greater  diversity  of  manifestations,  and 
about  which  more  has  been  written.  Its  absorb- 
ing interest  is  due  mainly  to  the  peculiar  char- 
acter and  unlimited  possibilities  of  its  expres- 
sion. Surely,  a  disease  is  worthy  of  the  con- 
sideration which  has  been  bestowed  upon 
hysteria  when  it  is  capable  of  causing  such 
diverse  s^nnptoms  as  paralysis,  con^Tilsions, 
blindness,  multiple  personality,  and  which  can 
occur  in  epidemics  that,  in  the  past,  have  caused 
greater  disturbance  to  whole  nations  than  a 
war  would  have  occasioned.  Its  history  and 
literature,  which  would  fill  a  spacious  library, 
show  that  from  the  days  of  the  Grecian  oracles, 
or  of  the  sibyls  of  even  more  distant  ages,  to 
the  present  trance  mediums,  the  unfortunate 
Adctims  of  the  disease  have  been  subjected  alter- 
nately to  persecution  as  witches  and  demons,  or 
to  devotion  as  the  inspired  source  of  wisdom 
and  of  supernatural  knowledge. 

It  is  only  recently,  and  through  psychologic 
means,  that  hysteria  is  beginning  to  be  under- 
stood. The  credit  for  elucidation  of  problems 
of  the  disease  is  due  principally  to  the  French. 
In  fact,  the  psychology  characteristic  of  their 


4  PsycJiopathology  of  Hysteria 

nation  truly  may  be  said  to  have  been  based 
npon  studies  of  the  abnormal  psychology  of 
hysteria.  The  present  era  of  enlightenment  con- 
cerning the  disease  may  be  considered  to  have 
been  initiated  by  Bernheim.  It  is  his  interpre- 
tation— which  to  a  great  extent  has  stood  the 
test  of  time — of  the  phenomena  of  hypnotism 
that  enabled  this  earnest  investigator  to  grasp 
the  mysteries  of  hysteria  in  a  manner  which 
never  before  had  been  possible.  In  spite  of  the 
greatest  opposition  and  acrimonious  contro- 
versy, his  views  of  the  causation  and  nature  of 
many  of  the  symptoms  of  hysteria  are  obtaining 
at  last  the  recognition  and  acceptance  which 
they  deserve.  Babinski,  for  instance,  the  most 
ardent  of  the  revisionists,  eagerly  contends 
now,  as  Bernheim  insisted  many  years  ago,  that 
suggestion  is  of  the  utmost  importance  in  the 
genesis  of  symptoms  of  the  disease.  It  is  to 
Janet  that  credit  is  due  for  the  theory  that  dis- 
sociation of  the  personality  is  the  underlying 
mechanism  of  hysteria,  and  also  for  innum- 
erable and  valuable  experimental  researches 
concerning  the  psychic  nature  of  the  dis- 
turbances of  sensory  perception.  Of  great  im- 
portance, too,  was  his  exposition  of  the  somnam- 
bulistic qualities  of  many  of  the  manifestations. 
In  this  country,  the  most  fruitful  investiga- 
tions haA'-e  related  to  dissociation  of  the  person- 
ality; a  subject  which  has  received  considerable 
attention.     Probably  the  most  extensive  and  the 


Preface  5 

most  valuable  contributions  on  the  clinical 
study  of  this  condition  have  been  made  by  Mor- 
ton Prince  and  by  Boris  Sidis. 

Finally,  the  studies  of  Sigmund  Freud,  sub- 
jected at  "first  to  neglect  and  later  to  opposi- 
tion, now  are  exerting  an  enormous  influence  in 
revising  our  conceptions  of  hysteria.  The  ex- 
haustive manner  in  which  this  Austrian  studied 
his  cases  is  remarkable.  Not  only  have  his  ob- 
servations been  a  revelation  of  the  importance 
of  psychic  insults  in  the  etiology  of  the  disease, 
and  of  the  remarkable  manner  in  which  disso- 
ciated or  submerged  memory  complexes  dom- 
inate the  hysteric,  but  they  have  been  of  the 
greatest  consequence  in  showing  how  normally 
one's  actions  and  mode  of  thinking  are  largely 
determined  by  motives  of  which  one  is  uncon- 
scious. 

In  spite  of  the  multitudinous  volumes  in 
Avhich  the  disease,  or  certain  of  its  symptoms 
and  mental  states  are  described,  but  few 
English  books  have  appeared  in  which  the  dis- 
ease as  a  whole  has  been  treated  on  the  basis  of 
the  results  of  modern  psychopathologic  re- 
searches. In  the  belief  that  such  a  volume  may 
not  overburden  the  already  great  ranks  of  those 
dealing  with  the  disease,  the  author. has  modestly 
attempted  to  meet  this  deficiency.  In  conclusion, 
this  work  is  based  upon,  in  fact  is  an  exposition 
of,  the  modern  conception  of  hysteria  as  enter- 
tained by  the  foremost  contemporary  students 


6  Psychopathology  of  Hysteria 

of  abnormal  psychology.  A  not  inconsiderable 
amount  of  personal  experimentation  and  clinical 
investigation  has  been  drawn  upon,  and,  not 
desiring  the  responsibility  to  rest  upon  the' 
shoulders  of  others,  it  is  necessaTy  to  ac- 
knowledge, also,  that  some  personal  views  con- 
cerning the  disease  and  its  symptoms  have  been 
incorporated. 

Philadelphia,  Pa. 


CONTENTS 

CHAPTER  PAGE 

Preface 3 

I     Preliminary  Considerations 11 

II     Etiology 31 

III  Disturbances  of  Sensory  Perception..     56 

IV  Disturbances  of  Sensory  Perception : 

The  Special  Senses 89 

V     Visceral   and   Circulatory   Derange- 
ments    136 

VI     Psycho-Motor  Disorders 173 

VII     Psycholepsy 212 

VIII     Alterations  of  Consciousness 268 

IX    Multiple  Personality  and  Amnesia. .  312 
X    Hysteric  T empei^ament ,  Suggestibil- 
ity, Delusions,  Insanity,  Theories . .   354 
XI     Diagnosis,  Prognosis,  Treatment ... .  394 


PSYCHOPATHOLOGY  OF 
HYSTEEIA 


PSYCHOPATHOLOGY 
OF  HYSTERIA 

CHAPTER  I 
Preliminary  Considerations 

THE  normal  personality  may  be  regarded 
as  a  highly  mutable  synthetic  product 
of  memories  of  past  instruction  and 
experiences  as  modified  by  present  per- 
ceptions, either  of  external  stimuli — exogenous 
— or  of  the  countless  number  of  various  sen- 
sory impressions  arising  as  a  result  of  the  activ- 
ity of  the  different  structures  of  the  body — 
endogenous  or  coenesthetic.  By  reason  of  the 
modifying  influence  of  present  external  stimuli 
one's  personality  seems  to  undergo  the  greatest 
variation  in  accordance  with  the  difference  in 
his  reactions  to  diverse  environments;  the  mode 
of  reaction  suitable  for  one  kind  of  environment 
being  of  pathologic  import  if  displayed  in  an- 
other. As  the  memories  of  all  experiences  are 
fused  with  the  personality,  and  as  memories  are 
never  destroyed  except  by  gross  organic  disease 
of  the  brain,  every  event  in  a  person's  life  inevi- 
tably exerts  an  influence  upon  his  individuality 
— upon  his  manner  of  reacting  to  his  environ- 
ment. 

11 


o 


12  Psychopathology  of  Hysteria 

In  connection  with  the  laws  that  "all  nervous 
function  is  conditioned  upon  sensation,"  and 
that  all  sensory  impressions  invariably  become 
transformed  into  immediate  or  delayed  move- 
ment, or  action,  W.  K.  Walker  states :  ' '  That 
which  is  present  in  the  mind  at  any  given  in- 
stant is  therefore  due  to  its  past  experiences; 
to  previously  experienced  sensations,  impulses, 
ideas,  and  emotions.  These  'stored  up'  'sensa- 
tions tend  to  final  transformation  into  action' — 
that  is,  either  action  or  restraint  of  action, — 
not  only  according  to  the  laws  governing  all 
neural  and  mental  manifestations  in  general, 
but,  in  particular,  with  the  gradually  acquired 
habit  of  reaction  of  the  individual  organism." 
(Med.  News,  Jan.  28,  1905.) 

By  saying  that  we  have  forgotten  something, 
we  mean  only  that  we  are  unable  at  the  time 
to  reproduce  the  memory — to  raise  the  memory 
above  the  threshold  of  consciousness.  In  spite 
of  our  efforts  to  recall  them,  such  memories  re- 
main dormant  only  because  we  have  been  unable 
to  obtain  the  proper  association  of  ideas,  and 
at  any  subsequent  time  reproduction  can  be 
effected,  providing  that  the  proper  stimulus  is 
called  into  play.  Now,  even  though  events  have 
been  "forgotten,"  still  their  dormant  memories 
continue  subconsciously  to  influence  the  actions, 
feelings,  and  mode  of  thinking  of  the  individual. 
We  act  more  or  less  in  accordance  with  our  feel- 
ings and  our  general  conceptions,  and  though 


Preliminary  Considerations  13 

we  may  forget  in  what  manner  these  have  been 
originated,  vet  the  influence  of  the  underlying 
forgotten  occurrences  persists.  One  may  not  re- 
member just  how  the  knowledge  w^as  first 
acquired  that  heat  may  cause  pain,  but  the 
deficiency  in  our  ability  to  reproduce  these 
memories  does  not  impair  the  value  of  a  con- 
ception which  has  largely  been  the  product  of 
painful  experience. 

The  acquisition  of  knowledge,  through  personal 
experience,  requires  at  first  the  conscious  memory 
of  particular  causes  and  effects,  but  later,  these 
details  subside  below  the  level  of  consciousness, 
unless  the  occurrence  has  been  noteworthy,  and 
only  general  conceptions  remain.  Consequently, 
my  knowledge  that  fire  may  cause  pain  does  not 
necessitate  recollection  of  the  many  times  when 
fire  has  caused  me  to  experience  pain.  In  this 
respect,  then,  a  certain  amount  of  submergence 
of  memories  is  a  normal  concomitant  of  psychic 
development,  and  its  value  lies  in  the  freedom 
which  it  insures  from  being  mentally  en- 
cumbered mth  countless  and  useless  facts.  Ac- 
cepting as  true  these  well  known  characteristics 
of  the  human  mind  we  may  conclude  that, 
excepting  possible  hereditary  factors  and  the 
effects  of  education,  an  individual's  personality 
is  of  a  certain  nature,  mainly  because  of  the 
character  of  memories  of  countless  experiences 
in  which  he  has  taken  part;  these  memories, 
whether    conscious    or    submerged,    becoming 


14  Psychopathology  of  Hysteria 

integrals  in  the  continual  growth  of  the  person- 
ality. 

It  is  for  this  reason  that  one  evil  act  paves 
the  way  for  another,  and  that  no  one  can  do 
wrong  once  with  the  intention  afterwards  to 
forget  about  the  unpleasant  act,  and  thus  be 
free  from  harmful  consequences.  Each  act  or 
thought  of  an  individual  tends  towards  the 
recurrence  of  similar  acts  or  thoughts — the 
production  of  a  habit.  In  terms  of  materialism, 
this  fact  is  explained  as  being  the  result  of* 
lowered  synapsal  resistance.  Otherwise,  a  cer- 
tain kind  of  reaction  having  occurred  in  re- 
sponse to  a  given  stimulus,  we  assume  that, 
whether  conscious  or  dormant,  the  memory  of 
the  experience  largely  determines  repetition  of 
the  same  reaction  when  a  similar  stimulus 
occurs.  The  economics  of  this  tendency  are 
easily  grasped,  for  all  forms  of  normally  auto- 
matic activity  are  but  examples  of  acquired  re- 
flexes due  to  habitual  modes  of  volition,  an  i  if 
it  were  not  for  such  automaticity  one's  atten- 
tion would  constantly  be  employed  by  the 
performance  of  the  ordinary  acts  of  life,  at  the 
expense  of  higher  forms  of  activity  and  of 
acquisition  of  knowledge. 

To  the  normal  process  of  forgetting,  let  us 
apply  the  term  dissociation  with  the  under- 
standing that  this  designation  implies  merely 
that  though  certain  memories  have  subsided 
below^the  level  of  consciousness  their  influence 


Preliminary  Considerations  15 

still  persists  in  that  they  exert  a  continual  ef- 
fect upon  modes  of  thinking  and  of  acting.  In 
discussing  this  question  Ernest  Jones  has  writ- 
ten :  ' '  We  are  beginning  to  see  man  not  as  the 
smooth  self-acting  agent  he  pretends  to  be,  but 
as  he  really  is,  a  creature  only  dimly  conscious 
of  the  various  influences  that  mould  his  thought 
and  action,  ...  "  (Rationalization  In 
E very-Day  Life,  Jour,  of  Abnormal  Psych.,  Vol. 
3,  p.  168.)  No  matter  if  one  does  think  that 
he  knows  the  mechanism  and  all  the  motives 
of  any  given  act  or  thought,  these  have  been 
originated  or  modified  by  memory  complexes 
which  are  more  or  less  completelj^  dormant. 
Upon  becoming  acquainted  with  an  estimable 
person,  and  without  knowing  the  cause,  one 
may  experience  towards  him  an  '' instinctive" 
dislike.  Later,  the  true  reason  flashes  into 
mind:  it  was  because  the  object  of  aversion 
resembles  another  individual  who  had  wronged 
him  in  some  manner. 

If  we  should  stop  a  moment  to  consider  one 
of  our  most  cherished  ideas,  perhaps  we  would 
not  be  able  to  recall  the  reasons  which  had  led 
us  to  the  adoption  of  that  particular  belief ;  yet 
we  know  that  there  were  a  number  of  factors 
which  determined  its  growth,  and  which  con- 
tinue subconsciously  to  control  us.  Often  we 
hear  some  one  honestly  make  a  positive  asser- 
tion with  all  the  assurance  that  would  be  war- 
ranted by  thorough  knowledge  of  the  subject. 


16  Psychopathology  of  Hysteria 

Let  a  question  arise  concerning  the  grounds  for 
his  convictions  and  at  once  he  is  at  a  loss  for 
data  with  which  he  can  justify  his  assertion, 
even  though  he  knows  that  formerly  he  was 
cognizant  of  these. 

Our  supposed  knowledge  of  the  motives  for 
our  thoughts  and  actions  is  exceedingly  super- 
ficial and  illusory,  and  constantly  we  are  the 
unconscious  slaves  of  our  past.  In  this  sense,  at 
least,  we  have  not  any  freewill,  and  we  are  but 
the  automata  with  superadded  consciousness 
about  which  so  much  has  been  written ;  reacting 
as  we  do  to  our  present  environment,  according 
to  the  influence,  more  or  less  unconscious  to  us, 
of  the  past  surroundings  in  which  we  have  been 
placed  merely  as  a  matter  of  accident,  as  far  as 
our  own  inclinations  were  concerned.  In  the 
last  few  years  even  more  acceptably  might  have 
been  written   Spinoza's   celebrated  remark  to 

the  effect  that  '^ men  think  themselves  free, 

inasmuch  as  they  are  conscious  of  their  volitions 
and  desires,  and  never  even  dream  in  their  igno- 
rance, of  the  causes  which  have  disposed  them 
to  wish  and  desire."     (Ethica,  Elmes  trans.) 

To  illustrate  the  agency  of  subconscious  mem- 
ory complexes  there  is  no  better  example  than 
the  "Frost  King"  episode  in  the  case  of  Helen 
Keller.  "When  twelve  years  of  age  Miss  Keller 
wrote  a  story,  which  she  called  the  "Frost 
King,"  and  it  was  published  in  one  of  the 
Perkins's    Institution    Reports.     Afterwards    it 


Preliminary  Considerations  17 

was  discovered  that  this  story  was  a  duplicate 
in  ideas — and  in  places  even  words — of  another 
story  which  had  been  read  to  her  three  years 
before,  or  a  little  over  one  year  after  she  had 
acquired  the  faculty  of  language — the  sign  lan- 
guage. 3Iiss  Keller  was  totally  unable  to  re- 
member the  original,  and,  until  convinced  by 
the  facts  of  the  case,  she  was  equally  positive 
that  hers  was  entirely  the  product  of  her  o^vn 
mind.  (The  Story  of  My  Life,  1903.)  It  must 
be  remembered  that  this  excellent  instance  of 
unconscious  plagiarism  is  an  unusually  exag- 
gerated one,  because  of  the  limited  amount  of 
knowledge  possessed  at  that  time  by  Miss  Keller, 
and  because  of  the  fact  that  by  reason  of  cer- 
tain mental  characteristics  and  of  the  difficulties 
under  which  she  labored  what  she  had  once 
learned  subsequently  tended  to  almost  complete 
reproduction,  without,  however,  being  coupled 
^vith  the  associated  ideas  of  source.  For  this 
reason  a  thought  might  be  considered  by  her  to 
be  original,  when,  in  reality,  it  arose  from  her 
subconscious  store-house  of  what  had  been  read 
to  her.  The  Hindoo  cycle,  in  the  case  of  Helene 
Smith,  almost  parallels  the  above  occurrence 
both  in  the  accuracy  and  in  the  unconsciousness 
of  the  plagiarism.  (Flournoy:  From  India  to 
the  Planet  Mars,  1901.) 

The  tendency  to  unconscious  plagiarism  is  not 
abnormal;  nor  is  it  unusual.  Let  one  who  is 
open  to  conviction  read  an  authoritative  book. 


18  Psychopathology  of  Hysteria 

If  he  reads  much,  a  year  later  he  may  be  unable 
to  recall  the  facts  and  theories  which  it  con- 
tained, but,  nevertheless,  these  continue  to  exert 
an  influence  in  determining  his  own  conceptions, 
though  he  may  be  unaware  of  the  fact.  A  year 
or  so  later  let  him  read  the  book  again,  and  he 
will  be  surprised  to  find  that  beliefs  which  he 
thought  not  only  were  original  but  were  of  re- 
cent origin,  were  reallj^  derived  from  his  first 
reading  of  the  work. 

The  following  quotation  from  Hammond  is  a 
fine  example  of  the  activity  of  normally  forgot- 
ten memories:  ''A  friend  has  related  to  me 
some  circumstances  in  his  own  case  similar  to 
the  above,  and  illustrating  the  same  points.  In 
the  course  of  his  practice  as  a  lawyer,  it  became 
necessary  for  him  to  ascertain  the  exact  age  of 
a  client,  who  was  also  his  cousin.  Their  grand- 
father had  been  a  rather  eccentric  personage, 
who  had  taken  a  great  deal  of  notice  of  both  his 
grandsons — his  only  direct  descendants.  He  died 
when  they  were  boys.  My  friend  often  told  his 
cousin  that  if  his  grandfather  were  alive  there 
would  be  no  difficulty  at  getting  at  the  desired 
information,  and  that  he  had  a  dim  recollection 
of  having  seen  a  record  kept  by  the  old  gen- 
tleman, and  of  there  being  some  peculiarity 
about  it  which  he  could  not  recall.  Several 
months  elapsed,  and  he  had  given  up  the  idea 
of  attempting  to  discover  the  facts  of  which  he 
had    been    in    search,    when,    one    night,    he 


Preliminary  Considerations  19 

dreaiTied  that  his  grandfather  came  to  him  and 
said:     'You  have  been  trying  to  find  out  when 

J was  born;  don't  you  recollect  that  one 

afternoon  when  we  were  fishing  I  read  you  some 
lines  from  an  Elzevir  Horace,  and  showed  you 
how  I  made  a  family  record  out  of  the  work 
by  inserting  a  number  of  blank  leaves  at  the 
end?  Now,  as  you  know,  I  devised  my  library 
to  the  Eev. .  I  was  a  d — d  fool  for  giv- 
ing him  books  which  he  will  never  read!  Get 
the  Horace,  and  you  will  discover  the  exact 
hour  at  which  J was  born. '  In  the  morn- 
ing ail  the  particulars  of  this  dream  were  fresh 
in  my  friend's  memory.  The  reverend  gentle- 
man lived  in  a  neighboring  city ;  my  friend  took 
the  first  train,  found  the  copy  of  Horace,  and  at 
the  end  the  pages  constituting  the  family 
record,  exactly  as  had  been  described  to  him  in 
the  dream.  By  no  effort  of  his  memory,  how- 
ever, could  he  recollect  the  incidents  of  the  fish- 
ing excursion. '^  (Sleep  and  Its  Derangements, 
1869.)  What  is  of  particular  interest  in  this 
case,  is  the  fact  that  the  dissociation  was  so 
complete  that  conscious  recollection  was  impos- 
sible, yet  complete  synthesis  was  obtained  dur- 
ing the  dream.  Furthermore,  in  the  waking 
state,  the  lawyer  was  totally  unable  to  recognize 
the  personal  nature  of  the  memories  which  had 
been  recovered. 

Now,  let  us  suppose  that  independently  of 
consciousness  dissociated,   or  submerged,  mem- 


20  Psychopatkology  of  Hysteria 

ories  become  integrated  with  one-anotlier,  or 
that  a  massive  dissociation  of  complexes  from 
consciousness  should  occur,  in  consequence  of 
some  psychic  insult,  and  that  the  dissociated 
fragment  of  what  constituted  the  more  or  less 
normal  personality  took  on  activity  irrespective 
of  the  present  states  of  consciousness  of  the 
Individual.  Such  processes  naturally  constitute 
pathologic  disaggregation  of  personality,  and 
if  the  offshoot  were  massive  enough,  a  secon- 
dary personality  would  be  produced. 

As  a  working  hypothesis  let  us  postulate 
that  all  the  functional  neuroses,  or  more  prop- 
erly psychoses,  are  dependent  upon  disintegra- 
tion of  personality,  and  that  as  such  they  are 
merely  the  result  of  pathologic  exaggeration  of 
what  is  a  normal  component  of  psychic  devel- 
opment. Then  neurasthenia,  psychasthenia,  hys- 
teria, and  multiple  personality  would  be  clinical 
syndromes  having  a  common  origin;  the  under- 
lying disintegration  being  rudimentary  in  the 
first  instance,  more  decided  and  often  suspected 
even  by  the  patient  in  the  second  one,  still  more 
developed  and  not  surmised  by  patients  suffer- 
ing with  the  ordinary  types  of  hysteria,  and 
massive  enough  to  be  complete  in  the  condition 
known  as  multiple  personality. 

By  means  of  this  prevalent  and  well  founded 
hypothesis,  almost  every  symptom  of  hysteria 
can  be  explained  as  satisfactorily  as  the  mani- 
festations and  pathologic  changes  of  any  organic 


Preliminary  Considerations  21 

disease.  Accordingly,  amnesia  results  from  ab- 
normally complete  or  massive  dissociation  from 
consciousness  of  certain  memories,  and  the 
proof  of  its  functional  character  can  readily  be 
adduced  by  means  of  reproduction  of  the  lost 
memories  through  the  agency  of  certain  well 
known  procedures.  Anaesthesia,  analgesia,  amau- 
rosis, deafness,  etc.,  would  imply,  on  the  other 
hand,  that  sensory  perceptions  had  not  become 
integrated  with  consciousness — that  they  had 
been  appropriated,  so  to  speak,  by  the  dissociated 
components  of  the  former  personality.  Experi- 
mentally, this  explanation  has  been  amply 
verified. 

After  adducing  experimental  observations  of 
Pierre  Janet,  Paul  Janet,  Binet,  Pitres,  and 
Bernheim,  concerning  phenomena  of  hysteria, 
no  less  authority  than  William  James  states: 
"It  must  be  admitted,  therefore,  that  in  certain 
persons,  at  least,  the  total  possible  consciousness 
may  he  split  into  parts  luhich  coexist  hut  mutu- 
ally ignore  each  other,  and  share  the  objects  of 
knowledge  between  them.  More  remarkable 
jstill,  they  are  complementary.  Give  an  object 
to  one  of  the  consciousnesses,  and  by  that  fact 
you  remove  it  from  the  other  or  others.  Bar- 
ring a  certain  common  fund  of  information,  like 
the  command  of  language,  etc.,  what  the  upper 
self  knows  the  under  self  is  ignorant  of,  and 
vice  versa.' ^  (The  Principles  of  Psychology, 
Vol.  1,  p.  206,  1905.) 


22  Psych  opathology  of  Hysteria 

At  best,  our  knowledge  of  mental  processes  is 
superficial.  Moreover,  the  difficulty  of  describ- 
ing normal  and  abnormal  psychic  phenomena  is 
great.  Any  language  necessarily  must  be  a 
faulty  vehicle  for  conveying  the  thoughts  of  one 
individual  to  another.  A  group  of  words  is  in- 
capable of  reproducing  in  one  person  the  exact 
conceptions  of  another.  To  this  difficulty  is 
added  one's  inability  to  describe  briefly  and 
accurately  any  process.  Suppose  we  subject  a 
remark  to  the  same  kind  of  criticism  that  would 
be  attracted  by  the  description  of  a  mental  pro- 
cess. By  reason  of  poverty  of  words  and  in- 
exactness of  verbal  representation  we  say  briefly 
that  a  cigarette  is  smoking,  and  that  a  man  is 
smoking,  or  that  the  paper  burns,  and  that  he 
is  burning  the  paper.  In  reality,  the  man  neither 
smokes  nor  burns  the  paper,  and,  to  say  nothing 
of  his  own  part  in  these  acts,  these  phrases  are 
most  superficial  and  condensed  representations 
of  a  variety  of  most  complex  chemical  processes. 
In  the  same  manner  causation  always  must  be 
obscure.  Wliat  was  the  cause  of  destruction  of 
the  paper?  The  immediate  one  was  oxidation. 
This  was  superinduced  by  heat  which  the  man 
had  applied.  But  then  the  endless  chain  arises 
concerning  the  causes  of  the  man  wishing  to 
destroy  the  paper  that  was  not  destroyed,  but 
whose  chemical  components  were  merely  disso- 
ciated, to  be  recombined  in  a  different  manner 
and  with  the  addition  of  oxygen. 


Preliminary  Considerations  23 

In  describing  tlie  psychic  mechanism  of  hys- 
teria we  say  that  the  disease  is  caused  by  disso- 
ciation of  consciousness,  and  that  this  process 
causes  increased  suggestibility,  then,  in  the  next 
breath,  that  further  dissociation  may  result  as 
the  effect  of  this  symptom.  These  statements 
only  imply,  however,  that  a  vicious  circle  is 
formed.  The  same  process  is  apparent  in  the 
use  of  hypnotism.  By  means  of  suggestion  a 
subject  is  hypnotized.  The  increased  suggesti- 
bility produced  by  this  state  of  dissociation  then 
enables  us  to  induce  more  readily  further  disso- 
ciation. 

Two  individuals  being  exposed  to  the  same 
psychic  stress,  one  may  develop  hysteria,  and 
the  other  psychasthenia ;  the  difference  in  the 
two  syndromes  being  equivalent  to  difference  in 
the  modes  of  feeling,  thinking,  and  acting  of 
the  two  persons.  The  condition  of  the  one  who 
developed  psychasthenia  is  said  to  be  due  to 
dissociation  of  the  personality  and  that  as  a 
Consequence,  fear  and  expectant  attention  appear 
as  symptoms.  Then,  like  the  vicious  circle  of 
hysteria,  these  symptoms,  by  causing  further 
dissociation,  induce  various  other  phenomena. 

In  a  gross  materialistic  way  the  pathologist 
is  satisfied  when,  with  the  assistance  of  stains, 
microscope,  and  other  laboratory  apparatus,  he 
finds  that  certain  lesions  occur  more  or  less  con- 
stantly in  some  disease.  He  seems  to  be  con- 
tented with  this  knowledge — ^he  has  discovered 


24  Psychopathology  of  Hysteria 

the  cause  of  a  disease — yet  the  discovery  of 
these  lesions  does  not  explain  the  cause  for  the 
same  reason  that  dissociation  of  personality  does 
not  account  for  the  production  of  the  psy- 
choneuroses.  There  is  an  inherent  tendency  for 
one  to  believe  that  he  knows  much  about  a  dis- 
ease merely  because  he  possesses  some  knowledge 
of  the  anatomical  changes  which  are  really  con- 
comitants or  secondary  causes.  To  say  that 
lesions  of  the  islands  of  Langerhans  are  the 
cause  of  diabetes  does  not  explain  the  disease. 
Not  only  is  there  a  cause,  or  causes,  for  this 
sclerosis,  but  there  may  be  a  whole  succession  of 
pathological  processes  that  precedes  its  develop- 
ment. The  greater  part  of  pathology  consists 
only  in  a  superficial  knowledge  of  terminal  pro- 
cesses, and  the  only  advantage  it  has  over  psy- 
chopathology is  that  scales,  test  tubes,  and  a 
microscope  lend  an  aspect  of  scientific  precision 
which  cloaks  in  a  satisfactory  manner  our  real 
ignorance  of  causality.  In  spite  of  what  the 
materialistic  pathologist  would  have  one  believe, 
psychopathology  is  not  entirely  a  matter  of 
groundless  theories  based  upon  the  morbid  in- 
trospection of  deviates.  With  the  assistance  of 
association  reaction  time  experiments,  the  psy- 
chogalvanic reflex,  pulse  reactions,  etc.,  the  psy- 
chologist can  '' measure"  the  emotions  and  de- 
tect and  reveal  subconscious  ideation. 

In  the  early  studies  of  hysteria,  and,  in  fact, 
even  to  the  present,  it  was  customary  to  describe 


Preliminary  Considerations  25 

a  number  of  sjrmptoms  as  characteristic,  or  stig- 
matic,  of  the  disease.  Among  the  most  import- 
ant were  anaesthesia  and  concentric  contraction 
of  the  visual  fields.  We  are  beginning  to  under- 
stand, now,  that  these  '"stigmata"  are  only  ac- 
cidental phenomena,  which,  except  when  created 
by  reason  of  faulty  methods  of  examination,  are 
rather  unusual  if  not  rare.  It  was  only  by  rea- 
son of  the  suggestive  technique  of  the  ordinary 
examination  that,  until  recently,  the  occurrence 
of  ''stigmata"  was  so  common. 

The  recent  discussion  of  hysteria  before  the 
Paris  Neurological  Society  brought  out  the  quite 
general  recognition  of  the  fact  that  the  symptoms 
of  the  disease,  as  many  have  intimated  for  years, 
are  caused  by  suggestion,  and  that  what  have 
been  called  the  stigmata  usually  owed  their 
origin  to  examinations  by  physicians  who  dis- 
regarded, or  were  unaware  of,  the  effects  of  sug- 
gestion in  causing  the  conditions  which  they 
sought.  Certain  members  averred  that  by  at- 
tempting to  avoid  the  pathogenic  effects  of  sug- 
gestion during  their  examinations  of  hysteric 
patients,  they  no  longer  find  anaesthesia  and  the 
like,  provided  that  the  patients  had  not  been 
examined  previously  by  others.  In  fact,  the 
tendency  of  some  of  the  members  seems  to  have 
been  to  ascribe  to  suggestion  all  the  symptoms 
of  the  disease.  According  to  BabinsM,  for  in- 
stance, a  patient  is  not  hysteric  whose  symptoms 
are  incapable  of  being  reproduced  by  suggestion 


26  PsychopatJiology  of  Hysteria 

and  removed  by  persuasion.  Yet  Babinski  was 
one  of  those  who  formerly  opposed  the  conten- 
tions of  Bernheim,  to  the  effect  that  the  stigmata 
of  hysteria  are  merely  the  product  of  suggestion. 
Consequently,  his  present  views  possess  greater 
significance  than  if  he  had  upheld  the  theory 
from  the  beginning. 

If  it  is  desirable  to  establish  stigmata  of 
hysteria  let  us  confine  ourselves  to  the  only 
symptom  which  is  characteristic  of  the  disease. 
The  only  one  whose  presence  is  at  all  constant, 
and  whose  pathogenic  importance  cannot  be 
overestimated,  is  pathologic  increase  in  sug- 
gestibility. This  veritable  stigma  has  been  a 
prolific  cause  of  blunders  in  the  past  studies  of 
the  disease.  It  is  by  reason  of  its  agency  that 
any  enthusiastic  investigator  ordinarily  and  un- 
intentionally can  cause  whatever  he  may  wish 
to  find  in  support  of  his  views ;  no  matter  what 
these  may  be.  Thus,  one  can  appear  to  demon- 
strate that  the  symptoms  of  hysteria  are  due 
only  to  intentional  simulation,  or  that  any 
symptom  is  essential  to  the  existence  of  the 
disease.  At  la  Salpetriere,  for  instance,  there 
was  created  a  typical  epidemic  of  hysteric  con- 
vulsions which  influenced  for  years  the  study 
of  hysteria,  and  which  was  the  effect  solely  of 
an  elaborate  suggestive  training  and  of  psychic 
contagion. 

Since  Bernheim 's  recognition  of  the  danger 
of  misinterpretation  of  the  occurrence  of  symp- 


Preliminary  Considerations  27 

toms  of  hysteria  through  the  raore  or  less  un- 
conscious use,  or  rather  abuse,  of  suggestion  by 
the  observer,  the  understanding  of  the  disease 
has  advanced  considerably  at  the  expense  of 
numerous  theories  and  classic  experiments 
which  owed  their  very  existence  to  suggestion. 
Many  years  elapsed,  though,  before  the  full  sig- 
nificance of  the  well  known  cautionary  "be- 
ware of  suggestion"  of  this  pioneer  became  ap- 
preciated. The  delay  was  due  to  the  power- 
ful antagonism  exerted  by  Charcot  in  conse- 
quence of  his  total  disbelief  in  the  effects  of 
suggestion.  In  fact,  the  experiments  of  Char- 
cot and  his  followers  upon  hysteric  patients 
were  rendered  valueless  by  reason  of  their  dis- 
regard of  suggestion.  To  no  other  factor  than 
ignorance  of  the  possibilities  of  suggestion  can 
be  ascribed  the  ludicrous  experiments  and 
theories  of  Luys.*  and  others  of  the  Salpetriere 
school,  concerning  the  wonderful  effects  of 
magnets,  of  metals,  and  of  medicine  in  sealed 
glass  tubes. 

It  has  been  demonstrated  conclusively,  that 
because  of  this  increased  susceptibility  to  sug- 
gestion, so  invaluable  for  therapeutic  purposes, 
prolonged,  unnecessary,  and  repeated  neuro- 
logic examinations  of  hysterics,  their  associa- 
tion with  other  victims  of  the  disease,  and  their 
demonstration  before  clinics,  where  they  hear 


(♦Reported  and  exposed  by   Ernest  Hart  in  Hypno- 
tism, Mesmerism  and  the  New  Witchcraft,   1896.) 


28  Psychopathology  of  Hysteria 

descriptions  of  their  symptoms  and  of  the  dis- 
ease, both  create  symptoms  and  prolong  those 
already  in  existence.  Therefore,  one  can  read- 
ily appreciate  that  the  earnest  and  faultily  con- 
ducted studies  and  the  clinical  exploitation  of 
these  cases  formerly  was  responsible  for  an 
incalculable  and  irreparable  amount  of  injury. 

Recognizing  the  importance  of  increased 
suggestibility  in  producing  symptoms,  we  can 
commonly  interpret  the  classic  stigmata  as  arti- 
ficial creations.  As  such,  they  have  almost  as 
much  diagnostic  value  as  formerly;  providing 
that  their  production,  which  usually  cannot  be 
considered  justifiable,  is  thought  necessary. 
Then,  too,  the  acceptance  of  these  views  leads 
to  a  better  understanding  of  the  symptoma- 
tology of  hysteria,  and,  furthermore,  we  will 
have  advanced  one  step  in  the  pursuit  of  the 
first  cause. 

With  the  justification  afforded  by  the  con- 
ceptions of  the  modern  French  neurologists,  as 
briefly  indicated  in  these  few  prefatory  notes, 
the  symptomatology  of  hysteria  will  be  largely 
considered  upon  a  basis  of  suggestion,  and  the 
effects  of  the  abnormally  great  suggestibility  in 
creating  or  in  modifying  symptoms  intention- 
ally will  be  reiterated  with  the  purpose  of  call- 
ing attention  to  the  possibilities  of  unconscious 
abuse  of  this  characteristic  of  the  disease. 

A  fact  which  must  be  borne  in  mind,  one 
which  a  priori  must  be  true,  is  that  each  per- 


Preliminary  Considerations  29 

son's  hysteria  must  differ  just  as  the  mental 
characteristics  of  all  individuals  vary.  More- 
over, the  kind  of  symptoms  possessed  by  a 
patient  depends  entirely  upon  the  nature  of 
the  incidental  exciting  causes,  upon  the  per- 
sonal equation,  upon  psychic  contagion  from 
others,  and  upon  the  effects  of  accidental  sug- 
gestion. 

Bernheim  believes  that  it  is  impossible  to  de- 
&ie  hysteria  because  it  is  not  a  morbid  entity. 
According  to  Lasegue  hysteria  never  has  been 
defined  and  it  never  will  be.  In  a  more  hope- 
ful spirit  Grasset  does  not  despair  of  any 
progress,  but  he  believes  that  the  definition  is 
still  impossible.  In  spite  of  the  restrictions  of 
these,  and  other  neurologists,  the  definitions  of 
hysteria,  like  those  of  insanity,  are  almost  as 
numerous  as  the  writers  who  have  described 
the  disease.  Having  the  sanction,  then,  con- 
ferred by  numerous  precedents,  and  recognizing 
the  impossibility  to  define  satisfactorily  such  a 
protean  malady,  the  following  may  be  regarded 
merely  as  a  provisional  definition: 

Hysteria  may  be  designated  a  psychoneurosis, 
■or  so-called  functional  nervous  disease,  which, 
tending  to  develop  particularly  in  those  predis- 
posed by  neuropathic  heredity  and  by  \T.cious  en- 
^ronment,  is  dependent  upon  disintegration  of 
personality  and  is  characterized  by  symptoms 
originating  from  the  morbid  control  of  the 
body  by  subconscious  states ;  whose  s;\^mptoms 


30  PsychopatJiology  of  Hysteria 

can  be  shown  to  be  but  exaggerations  or  per- 
versions of  normal  modes  of  feeling,  of  think- 
ing, and  of  acting;  a  disease  which  is  distin- 
guished by  a  peculiar  type  of  temperament, 
faulty  adaptability  to  environment,  pathologic 
increase  in  suggestibility  resulting  in  the  liability 
to  develop  many  kinds  of  phenomena,  and  the 
possibility  of  the  appearance  of  any  one  or 
more  of  a  vast  number  of  "accidents"  arising, 
from  morbid  ideation. 


CHAPTER  II 

Etiology 

HEREDITY.  In  common  wiih  the  other 
psyehoneuroses,  hysteria  is  thought 
usually  to  occur  in  those  whose  nervous 
system  is  rendered,  as  a  consequence 
of  neuropathic  heredity,  more  susceptible  than 
usual  to  functional  derangement.  Undoubtedly 
this  is  true,  but  the  occurrence  of  hysteria  does 
not  necessarily  always  imply  the  instrumental- 
ity of  heredity,  or  the  existence  of  a  state  of 
organic  nervous  degeneracy.  In  fact,  the  family 
history  is  above  reproach  in  about  10%  to  20%  of 
cases  of  hysteria.  If  one  accepts  the  extreme  ^dews 
upon  degeneration  promulgated  by  Nordau* 
and  others,  then  but  few  families  could  be  con- 
sidered entirely  free  from  some  variety  of 
hereditary  psychopathic  taint. 

It  is  best,  therefore,  to  entertain  conserva- 
tive views  about  this  matter  and  to  limit  our 
conception  of  the  influence  of  neuropathic  he- 
redity to  those  cases  in  which  a  history  of 
epilepsy,  insanity,  dipsomania,  or  distinct  crim- 
inal tendencies  can  be  found  in  the  immediate 
ancestry. 

Direct  inheritance  of  hysteria  may  be  possi- 
ble, but  the  more  apparent  deleterious  effects 

♦Deg-eneration,  1897. 

31 


32  Psychopathology  of  Hysteria 

of  constant  association  of  the  offspring  with  a 
hysteric  parent  is  sufficient  to  account  for  those 
instances  in  which  the  disease  is  encountered  in 
two  consecutive  generations  of  a  family. 

A  broad  minded  view  of  the  part  played  by 
heredity  in  the  production  of  hysteria  is  to  hold 
the  opinion  that  the  disease  is  potential  in 
every  one,  and  that  the  potentiality  becomes 
more  decided  when  neuropathic  heredity  exists. 
Then  the  relationship  between  hysteria  and 
direct  heredity  is  practically  the  same  as  that 
in  tuberculosis;  direct  inheritance  of  either 
disease  being  rare,  and  the  usual  character  of 
transmission  being  that  of  increased  suscepti- 
bility. The  aptness  of  this  comparison  becomes 
more  evident  if  one  stops  to  consider  the  many 
families  in  which,  despite  the  existence  of  psy- 
choneuroses  in  the  parents,  the  children  present 
merely  a  nervous  type  of  temperament,  which 
is  not  decided  enough  to  be  regarded  patho- 
logic. 

The  potentiality  of  the  disease  in  every  one 
may  be  likened,  also,  to  the  general  suscepti- 
bility to  its  analogue,  hypnotism.  With  the 
exception  of  the  insane  and  of  the  psychas- 
thenics, whose  peculiar  mental  state  renders 
hypnosigenesis  difficult,  but  not  impossible,  as 
Janet  asserts,  about  90%  of  people  are  capable 
of  being  hypnotized ;  our  failure  to  succeed  with 
the  remainder  probably  being  due  to  lack  of 
patience,  and,  when  the  attempt  is  not  made 


Etiology  33 

for  therapeutic  purposes,  to  the  absence  of  a 
good  reason  for  its  induction. 

Environment.  Those  who  have  to  deal 
with  the  psychoneuroses  hear  the  complaint 
constantly  that  nervousness  has  been  engen- 
dered, as  well  as  aggravated,  by  that  of  those 
with  whom  the  individual  has  been  in  constant 
association.  It  is  usually  the  continual  irrita- 
tion, and  the  state  of  expectant  attention,  or 
auto-suggestion,  which  is  induced  by  the  pro- 
pinquity of  hj^steric  parents  that  increases  the 
liability  of  the  progeny  to  develop  the  disease. 
Then,  having  developed,  heredity  receives  the 
blame.  Under  the  caption  psychic  contagion 
the  influence  of  environment  will  receive  fur- 
ther attention. 

Faulty  Education.  As  hysteria  is  com- 
monly disposed  to  attack  those  who  have  not 
acquired  sufficient  emotional  stability,  self- 
control,  and  the  proper  appreciation  of  the  rela- 
tion between  self  and  the  outside  world,  any 
system  of  education  which  is  deficient  in  devel- 
oping these  qualities  may  lead  to  the  produc- 
tion of  the  disease. 

The  pernicious  effect  of  over  indulgent  par- 
ents is  great.  Faulty  conceptions  of  external 
relations  and  faulty  modes  of  reacting  to  other 
environments  are  produced,  and  these,  together 
with  the  effects  of  the  parent's  habitual  disre- 
gard of  emotional  outbursts,  constitute  a  kind 
of  temperament  which  cannot  be   other  than 


34  Psychopathology  of  Hysteria 

conducive  to  hysteria — if  not  already  a  feature 
of  the  disease.  Few,  indeed,  are  the  ' '  spoiled ' ' 
children  who  are  unselfish,  whose  tempers  are 
reasonably  controlled,  and  who  are  capable  of 
developing  into  self-reliant  men  and  women! 
Fortunate  are  the  children  of  the  poor  in  that 
they  are  less  apt  to  be  the  recipients  of  such 
undesirable  attentions ! 

Let  not  the  impression  be  gained  from  these 
sentences  that  hysteria  is  most  frequent  in 
children.  The  child  is  father  of  the  man,  and 
as  the  adult's  temperament  and  mode  of  reac- 
tion is  the  outcome  of  that  of  the  child,  early 
educational  methods  are  of  the  greatest  impor- 
tance either  in  the  causation  or  in  the  pro- 
phylaxis of  psychoneuroses. 

Age.  The  emotional  disturbances  charac- 
teristic of  pubescence,  and  the  unstable  psychic 
equilibrium  of  maturity,  the  period  of  great- 
est exposure  to  the  stresses  of  life,  naturally 
favor  the  onset  of  hysteria.  This  is  shown  by 
the  following  table  constructed  from  a  dispen- 
sary service  from  which  patients  younger  than 
15  years  were  excluded;  these  cases  being 
treated  in  another  department : 
Age.  15-20  25  30  35  40  45  50  55  60  65 
%  23      13    11    17    10     5      8      6      5      2 

Sex.  Because  of  their  inherent  emotional- 
ism and  relative  inferiority  in  logical  reasoning 
and  philosophical  acceptance  of  the  various 
inevitable  stresses  of  life,  females  are  more  sus- 


Etiology  35 

ceptible  to  hysteria  than  are  males.  The  dif- 
ference in  the  incidence  of  the  disease  in  the 
two  sexes  is  explained  by  Ziehen  as  being  due 
to  the  fact  that  the  psychic  reactions  which  nor- 
mally characterize  the  female  sex  closely  re- 
semble those  essential  to  hysteria.  (Modern 
Clinical  Medicine,  Diseases  of  the  Nervous  Sys- 
tem, p.  1048,  1908.)  It  is  the  absence,  too,  of 
the  hardening  effects  of  the  greater  responsi- 
bilities, which  are  shouldered  by  men,  that  is  a 
great  factor  in  producing  this  inequality. 

Even  more  unreliable  than  usual  are  the  sta- 
tistics concerning  hysteria.  As  all  the  psy- 
choneuroses  are  only  clinical  syndromes  de- 
pendent upon  the  same  psychic  abnormality 
— disaggregation  of  personality — it  is  impossi- 
ble for  neurologists  to  come  to  an  agreement 
over  the  disposition  of  the  borderland  cases. 
However,  most  stimulating  to  progress  in  the 
study  of  this  great  and  important  group  of  dis- 
eases is  the  difference  of  opinion  concerning 
their  classification.  The  personal  element  enters 
so  largely  into  the  collection  of  these  statistics 
that,  according  to  the  difference  in  their  concep- 
tions of  hysteria,  various  statisticians  have  col- 
lected figures  which  vary  as  much  as  50%. 
With  this  qualification,  then,  which  applies  also 
to  the  other  figures  in  these  pages,  the  ratio  of 
hysteria  in  males  and  females  lies  between  1  to 
3  and  1  to  6.  Careful  examination  of  the  rec- 
ords of  100   consecutive  cases  of  hysteria,  to- 


36  Psychopathology  of  Hysteria 

gether  with  revision  of  the  diagnosis  when  this 
was  considered  necessary,  showed  that  25%  of 
the  cases  were  males. 

Among  males,  by  no  means  is  it  the  effemin- 
ate man  who  is  most  apt  to  develop  hysteria. 
Experience  shows  that  the  disease  attacks  more 
frequently  the  hard  working  and  often  prosaic 
man;  the  reason  being  that  in  males  the  mani- 
festations almost  invariably  follow  traumatism, 
and,  consequently,  those  men  who  are  most  ex- 
posed to  physical  injury  are  the  ones  most 
liable  to  develop  hysteria.  Both  for  this  reason, 
and  on  account  of  the  less  dangerous  occupa- 
tions followed  by  women,  traumatic  hysteria 
occurs  more  frequently  in  men.  A  noticeable 
feature  of  the  disease  in  men  is  its  severity, 
and  its  tendency  towards  what  appears  to  be 
monosymptomatic  expression;  such  manifesta- 
tions as  paralysis,  mutism,  and  psycholeptic  at- 
tacks being  the  ones  most  commonly  observed. 

Social  Factors.  Though  the  relatively  de- 
ficient amount  of  education  possessed  by  the 
rural  population  and  the  hard  working  poor  of 
the  cities  renders  them  more  susceptible  to  the 
acute  epidemic  form  of  the  disease  they  are  less 
inclined  to  be  subject  to  essential  hysteria  than 
those  of  the  upper  urban  classes.  The  com- 
parative freedom  of  the  former  is  due  to  the 
fact  that  they  escape  the  over  refining  influ- 
ences of  a  life  of  idleness,  emotionalism,  and 
luxury,  and  that  their  psychic  equilibrium  is 


Etiology  37 

rendered  more  stable  by  what  usually  is  not  an 
abnormal  amount  of  responsibility.  Other  im- 
portant reasons  for  this  difference  are  afforded 
by  the  more  self-reliant  manner  in  which  their 
children  are  brought  up,  and  by  the  fact  that 
the  greater  freedom  of  these  children  causes 
them  to  be  less  exposed  to  psychic  contagion  in 
case  one  or  both  parents  are  neurotic.  Then, 
too,  the  fact  that  the  poor  marry  early  pos- 
sesses significance  in  that  it  lessens  materially 
the  exposure  to  a  certain  kind  of  emotional 
stresses  whose  importance  in  the  etiology  of 
hysteria  has  been  shown  to  be  too  great  to  be 
ignored. 

As  the  dregs  of  the  city  community  is  com- 
posed of  individuals  who  follow  lives  of  in- 
ordinate excitement  and  whose  passions  are  un- 
accustomed to  self-restraint,  and  as  this  social 
element  contains  an  undue  proportion  of  the 
truly  degenerate,  hysteria  is  not  only  frequent 
but  it  is  encountered  in  its  most  highly  elabor- 
ated forms.  The  disease  is  most  common,  there- 
fore, in  the  extremes  of  society. 

Occupation.  Certain  occupations  are  attend- 
ed with  an  increased  liability  to  the  develop- 
ment of  hysteria  because  of  the  emotionalism 
and  unsettled  mode  of  living  that  they  ne- 
cessitate. Particularly  is  this  the  case  when 
an  imaginative  or  artistic,  one  might  almost 
say  hysteric,  temperament  is  one  of  the  requis- 
ites.    Thus,    artists,    musicians,    authors,   and 


38  Psychopathology  of  Hysteria 

members  of  the  dramatic  profession,  are  fre- 
quently attacked  by  the  disease.  The  excessive 
anxiety  and  alternation  of  intense  emotions  en- 
tailed by  the  character  of  their  occupation  in- 
creases the  predisposition  of  stock  traders  and 
others  whose  fortunes  are  largely  dependent 
upon  chance. 

Race.  As  the  French  were  the  first  to  study 
extensively  and  to  write  about  hysteria,  it  was 
formerly  thought  that  this  disease  was  en- 
countered but  rarely  outside  of  France.  Since 
physicians  of  other  countries  have  become  better 
acquainted  with  hysteria,  and  thus  are  able  to 
differentiate  its  major  manifestations  from  those 
of  other  diseases,  this  erroneous  idea  has  dis- 
appeared. Because  of  their  emotional  tem- 
perament, however,  the  condition  probably  is 
more  prevalent  and  more  highly  developed  in 
people  of  the  Latin  races. 

Although  infrequent  as  a  distinct  endemic  dis- 
ease, epidemics  of  hysteria,  usually  of  a  religious 
nature,  are  not  uncommon  among  the  uncivilized. 
Indeed,  symptoms  of  hysteria  are  frequently  ob- 
served in  connection  with  the  religious  ceremo- 
nies of  savages,  and  these  manifestations  may  be 
the  true  source  of  certain  religious  beliefs. 

Climate. — Hysteria  is  more  frequent  in 
tropical  countries  because  these  are  inhabited 
mainly  by  the  Latin  races.  The  mental  effects 
of  a  new  environment  and  of  the  physical  dis- 
comfort caused  by  an  unaccustomed  amount  of 


Etiology  39 

heat,  together  with  the  stimulating  effects  upon 
emotional  activity  of  this  relatively  excessive 
heat,  results  in  tlie  production  of  an  unusual 
number  of  cases  of  psychoneuroses  among  North- 
erners wlio  liave  emigrated  to  the  tropics. 
Americans  residing  in  the  Philippines  seem  to 
he  particularly  prone  to  develop  neurasthenia. 
According  to  Louis  H.  Fales  "nearly  all  Amer- 
ican women  and  a  large  proportion  of  men  who 
have  been  in  the  Islands  one  year  or  more  suffer, 
at  least  to  some  extent,  with  nerve  exhaustion.  It 
is  conservative  to  state  that  50%  of  the  women 
and  30%  of  the  men  suffer  with  neurasthenia  to 
such  an  extent  that  they  are  in  a  state  of  semi- 
invalidism. "  (Amer.  Jour,  of  the  Med.  Sciences, 
1907,  vol.  1,  p.  583.) 

Exciting  Causes.  The  exciting  causes  may 
conveniently  be  divided  into  acute  psychic  insults 
and  chronic  mental  stresses. 

Acute  Psychic  Insults. — Traumatic  hysteria 
should  be  considered  the  result  of  the  acute 
mental  shock  of  an  accident  and  not  the 
physical  effect  of  traumatism.  For  instance, 
even  though  hysteric  paralysis  should  appear  in 
a  limb  immediately  after  it  has  been  injured,  ex- 
perimentally it  can  be  proven  that  the  paralysis 
is  entirely  psychic  in  nature,  and,  therefore,  un- 
der certain  conditions  the  affected  part  can  be 
used  in  a  manner  that  does  not  differ  from  the 
normal.  Indeed,  if  such  were  not  the  case  the 
paralysis  would  not  be  symptomatic  of  hysteria. 


40  Psychopathology  of  Hysteria 

Consequently,  the  direct  physical  effects  of  the 
injury  are  not  instrumental  either  in  producing 
or  in  maintaining  the  condition. 

Even  though  not  any  symptoms  of  the  disease 
had  ever  before  been  apparent  theoretically  any- 
one may  develop  a  simple  physical  manifes- 
tation of  hysteria,  or  even  a  more  elaborate 
form  of  the  disease,  as  the  immediate  or  de- 
layed consequence  of  a  severe  or  trivial  acci- 
dent. In  quite  a  few  cases  symptoms  first 
appear  after  a  surgical  operation.  Like  the 
ones  following  traumatism  these  do  not  result 
from  the  physical  effects  of  the  operation  but 
rather  from  the  anxiety,  actual  pain,  and  other 
distressing  features  of  what  is  a  novel  ex- 
perience. Often  the  manifestations  of  these 
post-operative  cases  are  elaborated  from  the  or- 
ganic symptoms  for  which  the  patients  were  op- 
erated, or  from  the  transient  ones  occasioned  by 
the  operation,  or  the  surgical  anesthesia.  In 
this  manner  various  pains,  anorexia,  vomiting, 
tympanites,  urinary  retention,  and  other  symp- 
toms may  be  prolonged  through  the  agency  of  a 
complicating  hysteria. 

Other  than  those  resulting  from  physical 
traumatism  probably  the  majority  of  cases  of 
acute  development  are  due  to  psychic  insults 
whose  nature  is  more  obvious.  To  this  large  class 
belong  the  ones  following  sudden  disappoint- 
ment, deaths,  and  illness  in  others,  or  in 
self.     The  emotional  perturbations  arising  from 


Etiology  41 

tumultuous  affaires  du  coeur,  or  from  ones 
which  have  resulted  in  disappointment,  are  pro- 
lific exciting  causes  of  hysteria.  Any  relatively 
severe  emotional  shock,  however,  is  capable  of 
acting  as  an  exciting  cause. 

Though  the  onset  of  hysteria  may  appear  to  be 
gradual,  yet,  upon  investigation,  it  will  often  be 
found  that  the  underlying  disintegration  took 
place  suddenly,  and  perhaps  even  that  it  ante- 
dated by  weeks  or  months  the  appearance  of 
symptoms;  this  '^ period  of  incubation"  having 
been  appropriately  designated  the  period  of 
meditation,  or  of  auto-suggestion.  Usually,  the 
more  acute  the  onset  the  more  typical  and  severe 
are  the  manifestations  and  the  less  complicated 
by  neurasthenic  symptoms  is  the  resulting  symp- 
tom complex.  Such  cases,  too,  are  more  amen- 
able to  treatment,  and,  after  recovery  has  taken 
place,  there  is  less  tendency  towards  recurrence. 

Chronic  Mental  Stresses.  The  many  possible 
chronic  exciting  causes  are  inseparable  from 
predisposing  factors.  They  include  such  diverse 
conditions  as  prolonged  illness,  chronic  organic 
diseases,  and  any  kind  of  long  continued  emo- 
tional strain  such  as  induced,  for  instance,  by 
familial  and  marital  difficulties. 

The  development  of  hysteria  in  those  afflicted 
with  organic  disease  often  is  most  misleading  to 
the  diagnostician.  It  is  easy  to  comprehend  how 
the  knowledge  that  one  is  afflicted  with  a  severe, 
incurable,   organic   malady,   together  with    the 


42  Psychopathology  of  Hysteria 

mental  effects  of  what  may  be  distressing  physi- 
cal symptoms,  is  most  conducive  to  the  gen- 
eration of  a  superimposed  hysteria.  In  epilepsy, 
for  instance,  how  frequent  is  the  interposition  of 
typical  epileptiform  seizures  of  hysteric  origin! 
Many,  too,  are  the  cases  of  multiple  sclerosis 
which  are  complicated  by  hysteria. 

Toxemia.  In  harmony  with  the  theory  that 
brain  cells  secrete  thought  it  has  been  con- 
tended that  the  psychoneuroses  are  directly 
caused  by  the  deleterious  effects  upon  the  nerve 
cells  of  autogenic  toxins.  Also  that  ingestion 
of  toxic  substances  is  capable,  in  the  same  man- 
ner, of  producing  these  conditions.  Experience 
shows,  however,  that  while  auto-intoxication  is 
quite  common  in  neurasthenia  and  psychasthe- 
nia,  it  is  not  frequent  in  cases  of  hysteria.  In 
view  of  the  fact  that  in  but  few  cases  of  the  pure 
forms  of  hysteria  can  any  evidence  of  toxaemia 
be  found,  another  view  of  the  mechanism  of  pro- 
duction not  only  is  possible  but  is  a  necessity. 
Granted  that  toxins  may  exert  a  direct  effect 
upon  nerve  cells,  does  not  this  act  only  as  a  pre- 
disposing factor  in  the  majority  of  cases  appar- 
ently due  to  toxagmia  ?  It  is  easy  to  conceive  of 
a  heightened  susceptibility  to  hysteria  as  a  re- 
sult of  the  state  of  mental  depression  caused  by 
a  chronic  auto-intoxication.  It  is  too  much  to 
expect  any  one  to  feel  well  whose  head  aches  and 
who  experiences  vertigo  and  other  unpleasant 
symptoms    as    consequences    of    toxaemia    from 


Etiology  43 

gastro-intestinal  disturbance.  The  state  of  men- 
tal depression  resulting  from  a  condition  of 
chronic  intoxication  only  decreases  cerebral  in- 
hibition so  that  in  the  presence  of  an  adequate 
exciting  cause  hysteria  can  develop  more  readily 
than  otherwise. 

A  common  error  is  to  ascribe  to  the  etiology  of 
hysteria  the  not  uncommon  autotoxis  due  to 
gastro-intestinal  derangements  which,  in  reality, 
are  secondary  effects  of  hysteria  and  not  the 
cause  of  the  disease.  One  has  only  to  remember 
the  effects  of  emotional  states  upon  digestion,  as 
shown  by  Pawlow,  Cannon,  and  others,  to  under- 
stand how  auto-intoxications  can  occur  as  com- 
plications of  hysteria. 

As  an  exciting  cause  of  hysteria  the  mechan- 
ism of  toxaemia  might  be  compared  with  the 
mode  of  production  by  drugs  of  hallucinations 
and  delusions.  No  one  knows  just  how  or  why 
a  drug  or  a  toxin  acts  upon  the  brain,  but  we 
do  know  of  the  extreme  variations  in  the  cere- 
bral effects  of  these  substances.  We  have  good 
reason  to  suspect  that  the  delusions  and  halluci- 
nations that  may  occur  during  certain  drug  in- 
toxications are  produced  reflexly,  and,  therefore, 
that  they  are  secondary  to  the  effect  of  the  drug 
upon  cerebral  inhibition.  As  such  they  are  com- 
pletely the  analogues  of  the  delusions  and  hallu- 
cinations of  dreams. 

Let  us  say  that  a  drug  does  not  directly  cause 
a  delusion  but  that  it  merely  diminishes  cerebral 


44  Psychopathology  of  Hysteria 

inhibition,  and  thus  permits  lower  forms  of  re- 
flex cerebration  whose  nature  is  largely  depend- 
ent upon  the  character  of  the  coenesthetic  im- 
pressions and  of  the  chance  external  stimuli 
which  are  perceived  at  the  time.  Furthermore, 
such  mental  activity  necessarily  must  be  based 
upon  the  character  of  previous  environment  and 
education. 

An  intoxicated  man  reacts  to  his  environment 
in  a  manner  that  is  more  or  less  completely  de- 
void of  the  control  of  cerebral  inliibition.  Conse- 
quently, his  actions  are  better  standards  of  his 
true  character  than  are  those  when  he  is  sober 
— ^when  he  has  assumed  his  mask.  One  cannot 
reasonably  assert  that  alcohol  so  acts  upon  the 
brain  cells  that  an  intoxicated  person  is  rendered 
pugnacious,  or  boisterous;  it  is  more  probable 
that  these  manifestations  are  revelations  of  the 
individual's  real  character  undisguised  by  cere- 
bral inhibition. 

After  taking  opium  a  commonplace  man  might 
experience  sleep,  which,  as  far  as  he  was  after- 
wards aware,  was  dreamless,  while  a  brilliant 
thinker  like  De  Quincy  or  Coleridge  would  un- 
dergo, with  or  "without  the  production  of  sleep, 
the  most  exhilarating  and  lucid  forms  of  intel- 
lectual activity.  Or,  quite  commonly  the  admin- 
istration to  a  nervous  patient  of  certain  hypno- 
tics not  only  may  be  devoid  of  any  tendency  to 
produce  either  dreams  or  sleep,  but  it  may  lead 
to  aggravation  of  the  symptoms  for  which  it 
was  given  and  to  the  production  of  new  ones. 


Etiology  45 

The  theory  advanced  by  Obersteiner  and 
Pryor  that  sleep  results  from  the  accumulation 
of  toxic  matter  is  analogous  to  the  theory  that 
hysteria  is  the  outcome  of  a  similar  condition. 
As  the  result  of  his  experimental  study  of  sleep 
Sidis  concludes  tliat  the  state  ''is  not  a  disease, 
it  is  not,  as  the  chemical  speculators  would  have 
it,  a  kind  of  narcosis  of  the  system  by  the  poisons 
of  fatigue  products"  but  that  it  is  "an  actively 
induced  passive  state  in  relation  to  the  external 
environment."  (Jour,  of  Abnormal  Psychology, 
vol.  3,  p.  189.)  Biologically  interpreting  sleep 
as  an  instinctive  reaction  of  defense,  Claparede 
avers  that  we  sleep  not  because  we  are  in- 
toxicated or  tired,  but  in  order  not  to  be  so. 
(ArchiA^es  de  Psychologic,  Feb.  and  Mar.,  1904.) 

The  strongest  argument  against  the  hypothesis 
that  in  consequence  of  the  direct  effects  of  the 
toxins  upon  the  structure  of  the  nerve  cells 
toxsemia  is  a  cause  of  hysteria  is  the  fact  that 
many  cases  occur  suddenly  after  accidents  and 
in  the  absence  of  toxaemia,  and  also  that  practi- 
cally every  symptom  of  the  disease  can  be  dupli- 
cated so  veritably  by  hypnotic  suggestion  as  to 
deceive  an  expert.  Naturally  the  whole  subject 
revolves  around  tlie  ancient  and  ubiquitous  prob- 
lem of  the  relation  between  brain  and  mind;  the 
time  honored  question  of  monism  and  dualism. 

Psychic  Contagion.  Not  only  is  psychic 
contagion  important  as  a  predisposing  cause 
but   its   significance   in   the   actual   production 


46  Psychopathology  of  Hysteria 

of  hysteria  cannot  be  emphasized  too  greatly. 
The  influence  of  psychic  contagion  is  par- 
ticularly noticeable  in  children  on  account  of 
their  normally  great  susceptibility  to  suggestion; 
the  suggestibility  which  is  the  cause  of  their  in- 
herent tendency  to  imitate,  and  which  enables 
them  to  acquire  knowledge  easily  by  reason  of 
the  ready  acceptance,  to  which  it  leads,  of  any 
statement  made  by  one  in  whom  they  have  con- 
fidence. 

Quite  commonly,  indeed,  children  are  en- 
countered who  present  accidents  of  hysteria 
identical  in  character  with  those  of  their  parents. 
I  can  recall  a  typically  hysteric  woman  who  had 
psych oleptic  attacks  simulating  focal  elipepsy 
whose  child,  after  witnessing  a  number  of  these 
seizures  and  hearing  his  mother  describe  the 
symptoms  of  which  she  was  conscious,  developed 
similar  crises.  Even  the  aura  and  the  march  of 
the  symptoms  were  duplicated.  In  fact,  the 
crises  of  more  than  25%  of  cases  of  psycholepsy 
can  be  traced  directly  to  similar  attacks  which 
the  patients  have  observed  in  others.  In  another 
instance  all  the  children  of  a  large  family  pos- 
sessed gastric  symptoms  like  those  of  their 
father's  "gastric  neurosis"  in  addition  to  cardiac 
symptoms  that  they  had  acquired  by  psychic 
contagion  from  observing  their  mother's  heart 
attacks. 

Among  school-children,  in  hospital  wards,  and 
in  dispensary  clinics,  the  effects  of  psychic  con- 


Etiology  47 

tagion  are  frequently  encountered.  Particularly 
is  this  true  of  large  clinics  where  many  cases 
of  psychoneurosis  have  the  opportunity  to  com- 
pare symptoms,  to  observe  the  physical  disabili- 
ties of  those  afflicted  with  organic  nerv^ous  dis- 
eases, and  to  hear  lectures  concerning  neurologic 
subjects.  One  patient  who  had  been  treated  for 
epilepsy  heard  a  description  of  the  procursive 
variety  of  epileptic  attack  during  a  clinic  of  which 
he  was  the  subject.  In  less  than  a  week  procur- 
sive seizures  developed  like  those  whose  descrip- 
tions he  had  heard.  This  led  to  question  of  the 
diagnosis,  and,  after  close  study,  it  was  found 
that  his  seizures  were  hysteric  in  origin. 

Another  patient  who  was  supposed  to  be  an 
epileptic,  though  there  was  good  reason  for  re- 
garding his  attacks  as  being  symptomatic  of 
hysteria,  acquired  a  lot  of  new  symptoms  of 
which  he  made  complaint  during  the  first  visit 
after  ha^dng  been  examined  by  students  in  a 
clinic.  All  of  these  new  conditions  were  ones 
whose  presence  had  been  sought,  and  their  genesis 
was  due  to  the  suggestive  manner  in  which 
inexperienced  students  had  conducted  their 
tests.  Even  the  most  carefully  conducted  ex- 
aminations, however,  may  be  followed  by  psycho- 
genetic  symptoms.  Recognizing  this  fact  Gowers 
stated  that :  ' '  Medical  inquiries  and  examina- 
tions often  suggest  to  patients  the  definite  ideas 
of  symptoms,  and  the  physician's  knowledge  of 
the  natural  association  of  symptoms  may  thus 


48  Psychopathology  of  Hysteria 

lead  to  their  consistent  grouping  in  a  mimetic 
malady,  even  when  there  is  not,  and  still  more 
when  there  is  deliberate  simulation."  (A 
Manual  of  Diseases  of  the  Nervous  System,  p. 
989,  1903.) 

In  addition  to  abnormally  great  hetero-sugges- 
tibility  psychic  contagion  resulting  from  patho- 
logic auto-suggestibility — expectant  attention — 
naturally  has  interfered  greatly  with  the  proper 
interpretation  of  the  incidence  of  certain  symp- 
toms, and  has  been  the  sole  cause  of  the  appar- 
ent verification  of  many  otherwise  baseless  theo- 
ries of  the  disease. 

The  dabbling  with  spiritualism  of  the  less  in- 
telligent is  an  especially  pernicious  factor  both  in 
predisposing  to  hysteria  and  in  producing  the 
disease.  For  obvious  reasons  it  is  usually  the 
credulous,  emotional,  imaginative,  and  highly 
suggestible  person  who  attends  seances  and  who 
believes  in  the  supposed  evidences  of  spirit  con- 
trol which  he  witnesses,  and  as  there  are  many 
manifestations  of  hysteria  among  these  pheno- 
mena he  is  fortunate  if  he  does  not  acquire  some 
by  psychic  contagion. 

More  harmful  are  attempts  to  become  me- 
diumistic.  When  an  individual  deliberately 
seeks  and  encourages  the  development  of  self- 
induced,  organized,  mental  dissociations,  such  as 
those  required  by  trance  states,  automatic  writ 
ing,  etc.,  he  is  but  creating  and  evolving  a 
tendency  that  subsequently  may  escape  his  con- 


Etiology  49 

trol  and  become  the  foundation  of  actual 
hysteria.  Even  the  successful  self-induction  of 
these  conditions  might  be  considered  with  good 
reason  proof  of  hysteria. 

Because  spiritualistic  enthusiasts  have  wit- 
nessed so  many  diverse  manifestations  of  hys- 
teria, and  because  quite  commonly  they  are 
well  posted  in  a  spurious  form  of  psychology,  or 
rather  abnormal  psychology,  if  hysteria  develops 
there  is  at  hand  a  wealth,  of  knowledge  of 
pathologic  symptoms  upon  which  autosugges- 
tion can  operate  in  the  production  of  a  most 
completely  developed  type  of  hysteria;  one  in 
which  the  disease  is  expressed  less  physically 
than  as  a  psychosis.  By  reason,  too,  of  their 
pseudo-knowledge  of  transcendental  psychology, 
philosophy,  and  metaphysics,  spiritualists  and 
Christian  Scientists  are  most  resistant  to  psycho- 
therapy, and  their  very  knowledge  prevents  the 
successfal  application  of  other  forms  of  treat- 
ment. 

Epidemic  Hysteria.  When  widespread,  psy- 
chic contagion  may  cause  veritable  epidem- 
ics of  what  is  regarded  by  some  as  hysteria, 
and  by  others  as  hypnotism.  Frequently  this 
occurred  in  the  Middle  Ages,  and  even  at  pres- 
ent the  tendency  has  not  entirely  disappeared. 
A  wave  of  epidemic  religious  hysteria  has  been 
known  to  sweep  over  an  entire  race  and  to  con- 
tinue until  interest  either  died  out  naturally  or 
until  it  was  directed  to  some  other  object. 


50  Psychopafhology  of  Hysteria 

The  ghost-dance  religion  of  onr  own  Indians 
is  an  excellent  example  of  an  epidemic  of 
psychic  contagion  in  a  partially  civilized  peo- 
ple. This  epidemic  is  particularly  interesting 
in  that  it  has  been  reported  so  carefully  by 
James  Mooney.  (Fourteenth  Annual  Report 
of  the  Bureau  of  Ethnology,  Smithsonian  In- 
stitute, Part  2,  1892-93.)  Incidentally,  the 
manifestations  of  epidemic  hysteria  among  sav- 
ages are  often  identical  with  those  which  have 
occurred  during  many  similar  epidemics  among 
highly  civilized  people. 

Epidemics  of  hysteria  have  usually  assumed 
a  religious  character  because  of  belief  in  the 
supernatural  entertained  by  those  who  were 
affected.  Through  lack  of  intelligent  appre- 
hension certain  accidental  phenomena  may  be 
ascribed  to  supernatural  agencies  with  the  re- 
sult that  abject  fear,  together  with  the  in- 
creased suggestibility  characteristic  of  mobs, 
leads  to  the  birth  of  an  epidemic.  Those  who 
are  most  liable  to  become  subject  to  these  in- 
fluences are  the  credulous,  the  superstitious, 
and  the  impressionable ;  ones  who  are  incapable 
of  thinking  for  themselves  and  who  are  de- 
pendent upon  others  for  guidance.  In  modern 
times  epidemics  of  hysteria  have  usually 
assumed  the  form  of  revivals,  and  have  oc- 
curred mainly  among  the  impressionistic  and 
highly  superstitious  negroes  and  Indians.  The 
best  example  of  a  comparatively  recent   epi- 


Etiology  51 

demic  among  intelligent  people  was  the  de- 
plorable New  England  witchcraft  episode. 

When  hysteria  becomes  epidemic  it  cannot 
be  considered  other  than  an  acute  transitory 
form  that  reveals  the  inherent  potentiality  of 
the  disease  in  all  people.  Not  infrequently  epi- 
demics occurred  in  convents,  and  as  in  these 
instances  the  number  of  those  exposed  was 
limited,  the  ubiquity  of  the  potentiality  is  re- 
vealed more  fully.  In  such  epidemics  not  a 
few,  but  the  majority,  if  not  all,  of  the  inmates 
were  affected.  The  effect  of  repression  of  the 
sexual  instinct  was  a  conspicuous  feature  of 
epidemics  involving  the  occupants  of  convents ; 
the  disease  being  expressed  mainly  by  what 
was  termed  demoniac  possession  of  which  a 
frequent  symptom  was  delusions  of  sexual  in- 
tercourse with  evil  spirits.  Since  the  exposi- 
tion of  Freud's  theories  of  hysteria  the  signi- 
ficance of  this  fact  can  be  grasped  more  intelli- 
gently. 

Man  tends  to  explain  to  the  best  of  his  ability 
phenomena  of  whose  nature  he  is  ignorant.  If 
he  believes  in  demons,  and  if  he  has  no  other 
more  plausible  explanation,  he  accounts  for  cer- 
tain unusual  incidents  by  assuming  that  they 
result  from  diabolic  agencies.  If  such  views  of 
an  individual  receive  popular  acceptance,  or 
if  they  are  prevalent  ones  of  the  age,  an  epi- 
demic of  demonophobia  may  be  the  outcome. 
In    the    study    of    vampirism,    demonophobia, 


52  Psychopathology  of  Hysteria 

witchcraft,  and  the  like,  we  have  to  deal  actually 
with  two  interdependent  epidemics ;  one  of  abject 
fear  of  the  possessed,  and  the  other  of  suggested 
evidences  of  possession. 

For  about  200  years  the  whole  of  Europe  was 
a  vast  charnel  house  owing  to  the  countless 
numbers  of  the  supposedly  possessed  who  were 
put  to  death  by  many  almost  inconceivable 
forms  of  torture.  The  discovery  of  an  anaes- 
thetic spot  was  sufficient  evidence  to  condemn 
an  individual,  and  very  lucrative  became  the 
profession  of  detecting  these  unfortunates.  The 
examiners  went  around  searching  for  anaes- 
thetic areas  in  those  who  were  suspected,  and 
just  as  physicians  seek  for  a  certain  kind  of 
angesthesia  and  by  their  examination  alone 
create  this  product  of  suggestibility,  so,  too, 
did  the  witch  hunters  seek  and  create  ''evi- 
dences" of  possession.  Consequently,  unnum- 
bered thousands  of  men,  women,  and  children 
owed  the  loss  of  their  lives  to  the  effects  of 
suggestion  and  to  the  ignorance  of  the  age  in 
which  they  lived.  The  history  of  such  epi- 
demics, including  our  own  small  one  of  witch- 
craft, besides  being  of  scientific  interest  scarce- 
ly can  be  other  than  conducive  to  reflections 
upon  the  injustice  and  barbarities  which  hys- 
terics have  received. 

Even  though  epidemic  hysteria  be  regarded 
merely  as  an  acute  and  transitory  form  of  the 
disease  its  symptoms,  nevertheless,  are  just  as 


Etiology  53 

severe  as  those  observed  in  the  most  completely- 
developed  cases  of  endemic  hysteria  occurring 
upon  a  decided  foundation  of  psychopathic 
heredity.  Epileptiform  convulsions,  various 
rhythmical  movements,  hallucinations,  delu- 
sions, and  trance  phenomena,  are  the  most 
common  of  the  severe  manifestations  which  are 
prone  to  occur  during  epidemics.  For  instance, 
in  describing  the  revivals  among  Southern  ne- 
groes, Davenport  writes:  ''At  many  of  the 
'big  quarterlies'  and  the  'protracted  meetin's' 
which  are  held  in  the  South,  there  are  scenes  of 
frenzy,  of  human  passion,  of  collapse,  of  cata- 
lepsy, of  foaming  at  the  mouth,  of  convulsion, 
of  total  loss  of  inliibition,  compared  with  the 
scorching  heat  of  which  the  Indian  ghost-dance 
seems  at  times  only  a  pale  moon."  (Primitive 
Traits  in  Religious  Revivals,  1906.)  During  the 
revivals  among  the  whites  of  Kentucky,  in  1800, 
among  other  manifestations  such  as  visions  and 
trances  the  same  author  describes  the  "bark- 
ing exercise:"  "The  votaries  of  this  dignified 
rite  gathered  in  groups,  on  all  fours.  Like  dogs, 
growling  and  snapping  the  teeth  at  the  foot  of 
a  tree  as  the  minister  preached, — a  practice 
which  they  designated  as  'treeing  the  devil!'  " 
Belief  in  the  doctrines  expounded  during 
pathologic  revivals  is  not  essential  to  con- 
tagion; in  spite  of  the  greatest  efforts  to  with- 
stand them  the  manifestations  might  appear. 
Thus  the  Rev.  Myron  Eells  spoke  of  the  Indian 


54  Psychopathology  of  Hysteria 

Shaker  religion:  ''It  seems  to  be  as  catching, 
to  use  the  expression  of  the  Indians,  as  the 
measles.  Many  who  at  first  ridiculed  it  and 
fought  against  it,  and  invoked  the  aid  of  the 
agent  to  stop  it,  were  drawn  into  it  after  a 
little,  and  then  they  became  its  strongest  up- 
holders." (Fourteenth  Annual  Report  of  the 
Bureau  of  Ethnology,  Smithsonian  Inst.,  p. 
748.)  A  typical  instance  is  quoted  by  Sidis: 
''A  gentleman  and  a  lady  of  some  note  in  the 
fashionable  world  were  attracted  to  the  camp 
meeting  at  Cone  Ridge.  They  indulged  in  many 
contemptuous  remarks  on  their  way  about  the 
poor  infatuated  creatures  who  rolled  over 
screaming  in  the  mud,  and  promised  jestingly 
to  stand  by  and  assist  each  other  in  case  that 
either  should  be  seized  with  the  convulsions. 
They  had  not  been  long  looking  upon  the 
strange  scene  before  them,  when  the  young 
woman  lost  her  consciousness  and  fell  to  the 
ground.  Her  companion,  forgetting  his  promise 
of  protection,  instantly  forsook  her  and  ran 
off  at  the  top  of  his  speed.  But  flight  afforded 
him  no  safety.  Before  he  had  gone  200  yards 
he,  too,  fell  down  in  convulsions."  (Psychol- 
ogy of  Suggestion,  p.  352,  1899.) 

Epidemic  hysteria  reflects  the  ignorance  of 
a  people.  In  fact,  it  is  the  direct  outcome  of 
their  state  of  unenlightenment  and  its  mani- 
festations are  the  expression  of  their  convic- 
tions.    Indeed,  one  would  be  safe  in  affirming 


Etiology  55 

that  among  the  intelligent  of  present,  or  of 
future  ages,  epidemics  of  demonophobia  and 
the  like  could  not  be  repeated.  The  history  of 
recent  times  shows  that  the  epidemics  of  de- 
moniac possession  of  the  Middle  Ages  have  been 
replaced  by  epidemics  of  religious  revivals,  of 
popular  spiritualism,  of  financial  bubbles,  etc. 


CHAPTER  III 

Disturhances  of  Sensory  Perception 

IN  the  minds  of  the  laity  paralysis  must  be 
accompanied  necessarily  by  numbness; 
paralysis  implying  that  the  affected  mem- 
ber must  ''feel  numb  and  dead."  In 
most  individuals  this  prevalent  idea  probably 
results  from  the  temporary  paralysis  and 
numbness  that  most  of  us  have  experienced 
after  having  slept  ^vith  the  head  pillowed  on 
the  arm.  Hj^notic  experiments  conducted 
upon  normal  persons  commonly  demonstrate 
the  existence  of  this  erroneous  conception;  one 
that  is  based  upon  valid  premises  drawn  from 
personal  experience.  If  the  suggestion  is  made  to 
a  hypnotized  subject  that  one  arm  is  paralyzed, 
then  comparative  tests  of  the  sensibility  of  both 
arms  will  reveal  almost  invariably  the  presence 
of  anesthesia  in  the  paralyzed  one.  This  re- 
sult is  obtained  even  when  the  experimenter 
has  been  most  careful  to  eliminate  the  possi- 
bility of  creating  the  anaesthesia  by  uninten- 
tional suggestion  in  his  method  of  making  the 
tests.  As  a  consequence,  then,  of  the  concep- 
tion that  numbness  is  a  symptom  of  paralysis, 
a  hysteric  person  who  develops  paralysis,  either 
organic  or  functional,  is  apt  to  have  an  asso- 
ciated numbness,  or  anaesthesia,  of  the  affected 
member. 

56 


Disturbances  of  Sensory  Perception      57 

Among  other  similar  cases  Bernheim  writes 
of  a  painter  who,  becoming  the  victim  of 
saturnism,  presented  wrist-drop  associated  with 
analgesia  of  the  dorsal  aspect  of  the  wrist  and 
hand;  the  palmar  surface  and  the  fingers  not 
being  involved.  The  analgesia  having  been 
readily  dispelled  by  means  of  suggestion,  Bern- 
heim remarks  that  according  to  the  patient's 
idea  it  was  the  dorsal  surface  of  the  hand  and 
wrist  which  seemed  to  be  the  seat  of  trouble ; 
it  was  there  that  his  imagination  localized  the 
motor  paralysis;  it  was  there,  also,  that  logi- 
cally he  created  a  sensory  paralysis.  Being  able 
to  flex  and  to  extend  the  fingers,  these,  in  the 
patient's  mind,  were  not  paralyzed,  and,  there- 
fore, not  anesthetic.  (Conception  du  Mot 
Hysteric,  1904,  p.  11.) 

Independently  of  paralysis  angesthesia  may 
be  evolved  in  a  number  of  ways.  Thus,  the 
transitory  numbness  following  minor  trauma- 
tism to  sensory  nerv^es  may  become  fixed  as  a 
psychic  anesthesia  through  the  instrumentality 
of  autosuggestion.  In  the  same  manner  the 
symptom  may  develop  on  the  basis  of  a  limb 
''going  to  sleep,"  or  from  the  numbness  that 
is  noticed  after  an  extremity  has  been  held  in 
a  constrained  position  for  a  considerable  length 
of  time. 

It  is  not  unusual  for  hemiangesthesia  to  ap- 
pear in  patients  who  have  a  fear  of  apoplexy, 
due,  perhaps,  to  the  occurrence  of  this  condi- 


58  Psycliopathology  of  Hysteria 

tion  in  some  relative  or  friend.  Constantly  ex- 
pecting to  become  hemiplegic,  and  believing 
that  hemianaesthesia  is  a  symptom,  or  even  a 
forerunner,  of  the  condition,  patients  may  de- 
velop hysteric  hemianesthesia  either  with  or 
without  paralysis. 

Often  it  has  been  noticed,  even  in  persons 
who  were  not  considered  to  be  subject  to  hys- 
teria, that  a  hand  engaged  in  automatic  writing 
became  anaesthetic  at  the  time.  The  explana- 
tion of  this  event  is  not  difficult.  In  order  that 
automatic  writing  can  occur  there  must  be 
coexistent  dissociation  of  consciousness  with 
elimination  of  the  automatically  functionating 
extremity  from  the  field  of  consciousness. 
Not  only  are  the  motor  functions  dissociated 
but,  commonly,  the  member  as  a  whole  is  elided 
from  consciousness  mth  the  result  that  sensory 
impressions  originating  in  the  part  are  not 
consciously  perceived. 

When  produced  by  any  of  these  means,  or 
by  similar  ones,  anesthesia  may  be  said  to  be 
autogenous.  Now,  if  a  certain  kind  of  anes- 
thesia be  considered  a  typical  symptom  of  hys- 
teria, and  if  it  is  diligently  sought  by  examin- 
ing physicians,  both  because  of  its  interesting 
features  and  on  account  of  its  supposed  diag- 
nostic import,  then  the  condition  intentionally 
or  unintentionally  may  be  created  in  the  patient 
through  the  agency  of  the  abnormally  increased 
suggestibility  that  is  characteristic  of  the  dis- 


Disturbances  of  Sensory  Perception      59 

ease.     Thus,  angesthesia,  and  other  symptoms, 
may  be  heterogenous. 

Parenthetically,  the  distinction  between  auto- 
suggestion and  hetorosuggestion  is  only  one  of 
convenience  in  that  these  two  terms  super- 
ficially indicate,  or  appear  to  indicate,  the 
source  of  the  suggestion ;  the  mechanism  of 
production  of  symptoms  by  either  form  of  sug- 
gestion being  the  same.  When,  by  reason  of 
a  faultj^  technique,  the  examining  physician 
unconsciously  creates  auEesthesia  in  a  patient, 
or  when  the  condition  is  deliberately  suggested 
upon  a  hypnotized  subject,  it  is  produced  only 
because  the  individual  accepts  and  acts  upon 
the  implied  or  the  evident  suggestion  that  has 
been  conveyed  to  him.  The  anesthesias  which' 
have  not  originated  from  medical  examinations 
usually  follow  some  injury  which  has  produced 
temporary  numbness  of  the  part,  and  the  symp- 
tom thus  suggested  is  fixed  as  a  psychic  anaes- 
thesia. In  the  ultimate  analysis  all  effects  of 
suggestion,  whether  apparently  due  to  auto- 
suggestion or  to  heterosuggestion,  are  in  reality 
examples  of  autosuggestion  which  has  been 
provoked  by  an  external  stimulus,  immediate 
or  remote. 

That  hysteric  anesthesia  is  almost  invaria- 
ably  the  product  of  a  faulty  technique  of  ex- 
amination can  easily  be  demonstrated  clinically. 
If,  for  example,  in  ten  consecutive  cases  whose 
tactile  sensibility  is  being  tested  for  the  first 


60  Psych  opathology  of  Hysteria 

time,  the  patient  is  told  to  close  her  eyes  and 
immediately  to  say  "now"  luhen  any  part  of  her 
body  is  touched,  anaesthesia  probably  will  not 
be  found  in  any,  unless,  perhaps,  and  this  is 
unusual,  autogenous  anagsthesia  had  already 
existed.  On  the  other  hand,  if,  in  a  similar 
number  of  cases,  the  patient  is  told  to  close 
her  eyes  and  say  "now"  if  she  is  able  to  feel 
herself  touched,  anaesthesia  will  be  discovered 
— created — somewhere  in  over  a  quarter  of  the 
cases,  providing  that  the  usual  unnecessarily 
prolonged  and  careful  examination  be  made. 

As  commonly  conducted  the  tests  contain 
even  a  greater  element  of  suggestion.  Perhaps 
the  physician  states  in  advance  that  he  intends 
to  examine  in  order  to  ascertain  if  she  has  lost 
the  feeling  of  any  part  of  her  body,  or  in  some 
other  way  unintentionally  conveys  the  impres- 
sion that  anaesthesia  is  expected;  that  it  is  a 
symptom  which  she  should  possess.  A  state  of 
expectant  attention  having  been  excited  by 
these  suggestive  remarks  the  examiner  pro- 
ceeds to  stimulate  various  areas  while  asking 
if  the  patient  feels  "this,"  or  if  she  can  feel 
"that."  Except  direct  hypnotic  suggestion  no 
better  means  could  be  employed  intentionally 
to  create  ansesthesia. 

The  more  prolonged  and  thorough  the  exami- 
nation of  sensibility  the  more  frequently  anaes- 
thesia will  be  found  and,  if  the  tests  are  re- 
peated   during    subsequent    visits,    it    will    be 


Disturbances  of  Sensory  Perception      61 

fortunate,  indeed,  if  one  out  of  ten  cases  escapes 
the  production  of  this  ''symptom."  It  is  the 
avoidance,  now,  of  such  faulty  methods  of  ex- 
amination that  has  caused  hemiangesthesia  to 
become  so  rare  in  the  practice  of  many  of  the 
French  neurologists  when  formerly  it  was  a 
common  symptom. 

These  facts  alone  show  that  the  experimental 
study  of  hysteria  is  largely  the  study  of  its 
symptomatic  increased  suggestibility,  and  that 
those  who  devote  their  time  to  the  investigation 
of  such  manifestations  as  anaesthesia  for  the 
most  part  are  really  not  dealing  with  essential 
symptoms  of  the  disease  but  with  the  reactions 
of  the  patient  to  suggestion. 

As  the  confirmed  hysteric  is  inclined  to  wan- 
der from  one  physician,  or  clinic,  to  another, 
the  examinations  of  the  first  few  physicians 
commonly  are  quite  sufficient  both  to  create 
and  to  render  more  or  less  permanent  certain 
"stigmata.''  Those  who  have  subsequently  to 
deal  with  these  old  and  repeatedly  examined 
cases  naturally  do  not  cause  by  their  own  ex- 
aminations the  production  of  these  symptoms, 
and,  no  matter  how  careful  their  technique, 
anaesthesia  and  the  like  will  probably  be  found 
for  the  reason  that- they  had  already  existed. 

In  the  case  of  Lizzie  B.,  a  patient  who  had 
been  examined  by  anotlier  physician  without  any 
sensory  deficit  ha^ang  been  noted,  the  conscious 
perception  of  tactile  stimuli  had  become  imper- 


62  Psychopathology  of  Hysteria 

lect  and  much  delayed.  After  having  been  asked 
to  state  which  side  had  been  touched,  the  stimuli 
were  referred  to  the  corresponding  point  on  the 
contralateral  member — allocheiria.  On  repeat- 
ing these  tests,  after  a  short  rest,  she  was  unable 
consciously  to  perceive  any  of  the  stimuli.  Thus, 
hysteric  angesthesia  was  created  by  the  examina- 
tion. Now,  by  telling  her  that  there  really  was 
nothing  wrong  with  her  sensibility,  that  she 
could  feel,  that  she  would  signify  her  perception 
of  each  stimulus  by  saying  ''now"  just  as  soon 
as  she  felt  it,  and  each  time  that  she  would  state 
exactly  where  she  had  been  touched,  both  anaes- 
thesia and  allocheiria  were  caused  to  disappear. 
These  conditions  did  not  return  so  long  as  she 
was  under  observation — over  a  year. 

As  typical  of  the  modern  reaction  from  the 
extreme  views  of  anesthesia  held  by  the  older 
observers  is  Babinski's  total  disregard  of  the 
infrequent  autogenous  angesthesia  by  his  sweep- 
ing assertion  that  angesthesia  is  always  the  result 
of  suggestion  during  medical  examinations  con- 
ducted with  a  faulty  technique.  In  support  of 
his  contention  he  states  that  during  ten  years  he 
had  not  encountered  hemiangesthesia  among  hy- 
steric patients  who  had  not  been  previously  ex- 
amined by  others.  In  1910  Bernheim,  too,  as- 
serted that  since  1900  he  has  failed  to  discover 
hemianaisthesia  in  patients  examined  for  the 
first  time.  In  order  to  explain  the  absence  of 
the  condition  in  his  service  he  states :  ' '  To-day  I 


Disturbances  of  Sensory  Perception      63 

explore  with  the  idea  that  it  does  not  exist;  and 
this  idea  suffices  to  modify  my  technique  of  ex- 
amination, and  to  eliminate  its  suggestive  char- 
acter." (Hypnotisme  et  Suggestion,  Hysteric, 
Psychoneuroses,  etc.,  1910,  p.  269.) 

Now  there  must  be  some  way  of  reconciling 
such  statements  with  the  fact  that  other  ob- 
servers found  anaesthesia  in  from  75  to  95%, 
and  hemianaesthesia  in  30  to  50%  of  their 
hysteric  patients.  The  only  plausible  explana- 
tion for  such  conflicting  results  is  that  while 
formerly  physicians  created  anaesthesias  by  rea- 
son of  their  faulty  methods  of  examination,  now, 
on  the  contrary,  Bernheim,  Babinski,  and  others 
have  perfected  their  technique  of  examination 
to  such  a  degree  that  no  longer  do  they  suggest 
the  conditions  upon  the  patient. 

But  liow  account  for  the  absence  of  autogen- 
ous anaesthesia  and  hemianesthesia  in  the  prac- 
tice of  these  physicians  ?  If  it  suffices  to  produce 
ana3sthesia  merely  when  the  physician  expects  to 
find  sensory  deficits  and  examines  his  hysteric 
patients  in  accordance  with  his  views,  surely 
when  one  explores,  as  Bernheim  does,  with  the 
idea  that  the  condition  does  not  exist,  autogenous 
angesthesia,  if  present,  will  disappear  in  conse- 
quence of  the  fact  that  his  method  of  testing  ex- 
presses his  convictions.  In  the  first  instance  the 
suggestive  character  of  the  examination  is  patho- 
genic ;  in  the  second  one  it  is  therapeutic.  That 
such  an  explanation  is  not  improbable  is  indi- 


64  Psychopathology  of  Hysteria 

cated  by  the  fact  that  through  the  agency  of  in- 
tentional suggestion  it  is  just  as  easy  to  cause 
anaesthesia  to  disappear  as  it  is  to  create  the  con- 
dition. 

If  anaesthesia  were  not  usually  of  medical 
origin  certainly  the  statements  of  Bernheim  and 
Babinski  would  be  remarkable  in  view  of  the 
fact  that,  until  recently,  this  condition  was  one 
of  the  most  frequent  of  the  supposed  symptoms 
of  hysteria ;  so  frequent,  in  fact,  that  it  was  con- 
sidered stigmatic  of  the  disease. 

It  is  such  facts  as  these  that  lead  one  to  ques- 
tion all  theories  of  the  disease,  for  no  matter  how 
well  supported  by  facts  they  may  seem  to  be, 
and  no  matter  how  general  their  acceptance,  the 
history  of  the  malady  renders  only  too  evident 
the  eifeets  of  suggestion  and  of  psychic  conta- 
gion in  the  elaboration  of  innumerable  hypo- 
theses which  afterwards  were  proven  to  be  erron- 
eous. 

Less  radical  are  Janet's  views  concerning  the 
significance  of  anaesthesia.  To  express  the  dif- 
ficulty in  interpreting  the  psychologic  character 
of  hysteric  anaesthesia  he  writes:  ''Now,  your 
examination  alone  will  suffice  to  cause  a  real 
anaesthesia  to  disappear;  now — and  this  is  more 
serious — your  manner  of  interrogating  will 
create  outright  an  anaesthesia  that  did  not  exist. 
The  study  of  the  stigmata  is  made  on  no  patients 
so  well  as  on  old  ones;  real  pillars  of  the 
hospital,    who    have    already    been    examined 


Disturbances  of  Sensory  Perception      65 

thousands  of  times.  When  you  have  to  deal  with 
new  patients,  who  have  not  yet  been  touched, 
you  recognize  with  astonishment  that  anaesthesia 
is  rarer,  less  important  than  Charcot  said.  On 
this  point  I  apologize  myself,  and  acknowledge 
that,  under  the  influence  of  la  Salpetriere,  I 
formerly  attributed  more  importance  to  anaesthe- 
sia than  I  would  do  now."  (Major  Symptoms 
of  Hysteria  1907,  p.  274.) 

In  an  earlier  work  we  find  the  following  sig- 
nificant statement  pertaining  to  hysteria  in  the 
young :  ' '  The  patients,  in  the  beginning,  have  no 
anesthesia;  this  has  been  observed  by  all  au- 
thors." (Mental  State  of  Hystericals,  1892,  Cor- 
son trans.  1901,  p.  47.)  Why  do  not  young 
hysterics  present  anaesthesia?  Being  young 
these  patients  have  not  yet  been  examined  by 
numerous  physicians  and  thus  heterogenous 
anaesthesia  is  less  apt  to  have  been  created,  and 
because  of  their  age  they  are  not  apt  to  possess 
knowledge  of  such  a  condition  as  anesthesia  so 
that  it  is  not  liable  to  develop  as  an  autogenous 
symptom. 

In  connection  with  anesthesia  it  was  form- 
erly noticed  with  astonishment  that  what  should 
be  a  distressing  symptom  almost  never  was 
made  the  subject  of  complaint.  Or,  that  the 
majority  of  patients  were  not  aware  of  their 
sensory  deficit  until  this  was  revealed  by  an 
examination.  The  patient  might  exclaim: 
''Why,  I  never  knew  that  I  couldn't  feel  in 


66  PsycJiopathology  of  Hysteria 

that  arm!"  The  majority,  however,  expressed 
neither  surprise  nor  concern  when  the  physi- 
cian spoke  of  anaesthesia  which  he  had  found 
and  whose  existence  previously  had  been  un- 
known. 

By  means  of  the  argument  that  hysteric 
anaesthesia  is  only  subjective  and  that  as  such 
the  patient  really  perceives  tactile  and  other 
stimuli  but  that  the  perceptions  are  not  syn- 
thetized  with  consciousness,  exception  might 
be  taken  to  the  view  that  this  symptom  is  com- 
monly produced  only  by  suggestive  examina- 
tions. Though  quite  true  as  an  explanation  of 
the  inocuous  nature  of  existing  angesthesia 
logically  it  does  not  seem  legitimate  to  con- 
clude that  all  anaesthesias  antedate  the  exami- 
nation during  which  they  are  discovered  both 
by  physician  and  by  patient.  Practically,  the 
weight  of  evidence  is  overwhelmingly  against 
such  reasoning. 

In  their  conceptions  of  diseases  of  different 
parts  of  the  body  laymen  think  in  popular 
terms  of  arms,  legs,  halves  of  the  body,  etc., 
and  not  in  scientific  ones  of  peripheral  sensory 
distribution.  Naturally,  then,  hysteric  anass- 
thesia,  being  entirely  psychic  in  origin,  does 
not  conform  with  the  anatomical  peculiarities 
of  sensory  distribution.  The  one  conceivable 
exception  to  this  rule  is  the  possible  occurrence 
of  psychogenetic  angesthesia  limited  to  the  dis- 
tribution of  a  sensory  nerve  as  a  result  of  the 


Disturbances  of  Sensory  Perception       67 

fixation  of  transitory  numbness  provoked  by 
slight  traumatism  to  that  nerve.  The  atten- 
tion of  the  patient  having  been  directed  to  the 
symptom  and  to  that  particular  distribution 
unconscious  autosuggestion  amplifies  and  fixes 
the  primarily  organic  sj^mptom. 

In  view  of  its  anatomical  inconsistency  any 
anaesthesia  is  suggestive  of  hysteria  when  it  is 
limited  precisely  to  one  lateral  half  of  the  body, 
when  it  surrounds  an  arm  or  a  leg  like  a  glove, 
a  coat  sleeve,  a  stocking,  etc.,  or  when  it  occurs  in 
irregular  disseminated  patches.  Total  hysteric 
anaesthesia  is  most  exceptional. 

The  borders  of  organic  anaesthesia  are  fixed, 
or  varying  but  gradually,  and  they  are  not  well 
defined  because  of  the  overlapping  that  exists 
in  the  distribution  of  the  various  nerves.  Those 
of  hysteria,  however,  are  sharply  delineated 
and  varying  much  from  one  examination  to 
another,  and  even  during  the  same  examination. 
In  fact,  their  borders  can  be  determined  at 
will  according  to  the  use  of  suggestion  by  the 
examiner. 

The  following  instance,  mentioned  by  Prince, 
shows  how  readily  the  hysteric  is  influenced  by 
the  conceptions  of  her  physician,  and,  therefore, 
how  one  is  apt  to  discover,  or  unintentionally 
to  create,  whatever  one  expects  to  find:  "In  one 
instance  the  examining  physician,  thinking  the 
limiting  line  should  be  two  inches  from  the 
median  line  on  the  anaesthetic  side,  demonstrated 


68  Psychopath  ology  of  Hysteria 

this  boundary,  but  when  erroneously  told  it 
should  be  on  the  opposite  side,  corrected,  as  he 
thought,  his  faulty  observ^ation  and  demon- 
strated the  line  in  the  new  situation."  (Amer. 
System  of  Pract.  Med.,  p.  643.) 

Hysteric  anassthesia  does  not  occasion  loss  of 
the  reflexes  except,  perhaps,  those  of  the  skin, 
and,  during  sleep,  stimulation  of  an  anassthetic 
limb  not  only  may  cause  its  withdrawal  but  even 
verbal  remonstrances  may  be  provoked.  Also,  it 
has  been  noticed  that  hysteric  angesthesia  may 
disappear  during  the  exhilaration  caused  by 
drugs.  Finally,  there  need  not  be  any  impair- 
ment in  the  use  of  the  affected  member ;  with  her 
eyes  closed  the  patient  being  able  to  write,  for  in- 
stance, even  though  unable  consciously  to  feel 
the  pencil  she  grasps. 

Quantitatively,  hysteric  anaesthesia  may  be 
complete  or  incomplete;  conscious  perception 
either  being  absent  or  only  impaired.  Not  only 
the  skin  but  the  mucous  membranes,  or  both,  may 
be  involved.  Qualitatively,  any  one  or  all  of 
the  various  kinds  of  sensory  perception  are 
capable  of  being  the  subject  of  disturbances  sim- 
ilar to  those  of  tactual  perception.  In  hysteria, 
as  well  as  during  hypnosis  in  a  normal  person, 
it  has  been  noticed  that  small  wounds  in  an  an- 
aesthetic region  are  not  apt  to  produce  haem- 
orrhage or,  in  fact,  even  that  haemorrhage  may 
not  appear  at  all,  and  that  perspiration  may  be 
lessened  in  the  same  region. 


Disturbances  of  Sensory  Perception      69 

Let  us  examine  some  patients  and,  by  means 
of  suitable  experiments,  demonstrate  the  pecul- 
iarity of  hysteric  anaesthesia  and  attempt  to  de- 
termine its  nature.  The  most  easy  and  convinc- 
ing experiments  are  accomplished  with  the  aid 
of  h^'pnosis.  Numerous  ones  have  been  devised 
and  witli  a  little  ingenuity  anyone  can  contrive 
others  suitable  for  the  case  at  hand.  Sometimes 
one  ViWl  fail  while,  in  the  same  patient,  the  appli- 
cation of  another  is  attended  with  success.  If 
differentiation  from  organic  ansesthesia  depends 
upon  such  tests  alone,  one  successful  result  indi- 
cates that  this  one  symptom,  at  least,  is  hysteric 
in  origin  no  matter  how  many  other  experiments 
were  failures. 

Suppose  we  blindfold  a  patient  who  presents 
an  old,  well  organized,  and  complete  anesthesia 
and  then  lightly  touch  the  anaesthetic  region 
a  certain  number  of  times.  Upon  being  ques- 
tioned the  patient  asserts  positively  that  she 
has  not  felt  anything.  Now  we  hypnotize  her 
and  suggest  that  she  tells  us  how  many  tactual 
impressions  were  perceived.  Without  hesita- 
tion she  states  the  correct  number.  If,  in  a 
manner  that  is  not  too  obvious,  the  experi- 
menter suggests  to  the  patient  that  she  will  in- 
form him  of  the  number  of  the  impressions  tchich 
she  perceived  in  many  cases  a  successful  result 
wdll  be  secured  without  resorting  to  hypnosis. 

In  a  patient  with  long  continued  hemianges- 
thesia   occurring   in    association   with   organic 


70  Psychopathology  of  Hysteria 

hemiplegia  all  forms  of  sensibility  were  lost  on 
the  affected  side  of  the  body.  In  consideration 
of  the  history  of  the  patient,  together  with  the 
findings  of  a  hurried  first  examination,  it  was 
thought  that  the  sensory  loss  was  one  of  the 
consequences  of  a  cerebral  haemorrhage.  Im- 
mediately afterwards  he  was  carefully  ex- 
amined before  a  body  of  students.  Even  in 
this  patient,  one  familiar  with  many  clinics 
and  with  neurologic  examinations,  it  was  pos- 
sible, during  this  second  examination,  to  carry 
out  successfully  the  above  procedures  without 
resorting  to  hypnosis.  Disregarding  other  facts 
and  excluding  a  number  of  peculiarities  which 
were  inconsistent  with  organic  hemianaesthesia, 
the  results  of  these  tests  alone  would  have  been 
sufficient  to  prove  that  the  hemianesthesia,  at 
least,  was  hysteric  in  nature.  The  sensory  de- 
ficit was  too  general  and  too  absolute ;  he  ap- 
peared to  exhibit  absolute  loss  of  every  form 
of  sensibility  that  was  tested.  Thus  he  asserted 
that  he  could  not  feel  tactual,  painful  and 
thermal  impressions  and  that  osseous  sensibility 
to  the  tuning  fork  was  absent.  Even  though 
several  pounds  of  pressure  was  exerted,  suffi- 
cient to  push  his  leg  along  the  floor,  he  said 
that  he  felt  nothing.  When  the  affected  limbs 
were  placed  in  various  positions  and  he  was 
told  to  retain  these  passively  assumed  attitudes 
he  did  so  without  other  support  than  his  own 
efforts.     He  was  unable,  however,  to  duplicate 


Disturbances  of  Sensory  Perception       71 

these  postures  with  the  members  of  the  other 
side  because  as  he  asserted,  he  did  not  know 
where  the  paralyzed  ones  were  located.  Be- 
sides the  experiments  that  demonstrated  posi- 
tively his  perception  of  various  kinds  of  stimuli 
the  anomalous  character  of  his  sensory  losses 
was  sufficient  to  reveal  their  psychic  nature. 

During  examination  of  tactile  sensibility  it 
is  frequently  noticed  that  the  patient  starts 
slightly  whenever  the  anesthetic  region  is 
stimulated,  yet  consciously  she  does  not  per- 
ceive the  impressions. 

By  training  the  patient  to  carry  out  some 
simple  act  each  time  a  normal  area  of  the  skin 
is  stimulated  it  is  often  possible  to  obtain  the 
same  response  when  an  anaesthetic  region  is 
stimulated  in  the  same  manner.  Janet  has  suc- 
ceeded in  causing  the  patient  to  say  "yes" 
when  a  normal  area  of  the  skin  was  touched, 
the  patient's  eyes  being  shielded,  and  ''no" 
when  an  anaesthetic  area  likewise  was  stimu- 
lated. This  curious  result  was  obtained  by  tell- 
ing the  patient  in  advance  that  she  was  to  an- 
swer affirmatively  when  the  tactile  impression 
was  perceiA'ed,  and  negatively  when  it  was  not 
felt.  After  these  instructions  the  physician 
must  proceed  rapidly  with  his  tests  in  order 
not  to  give  the  patient  time  to  think  about  the 
inconsistency  of  the  replies.  Naturally,  too,  if 
she  is  intelligent  enough  to  remark  this  incon- 
sistency not  only  will  the  procedure  fail  but 


72  PsychopatJiology  of  Hysteria 

the  physician   exposes  himself  to   censure  for 
implying  that  she  was  malingering. 

The  same  author  speaks  of  a  patient  with 
hysteric  total  anaesthesia  upon  whom  elec- 
tricity was  being  employed  for  therapeutic- 
purposes.  One  day  it  was  noticed  that  on  each 
application  of  the  electrode  strong  muscular 
contractions  appeared  as  usual,  although  by 
accident  the  electrodes  had  been  disconnected, 
and,  furthermore,  the  patient  could  not  see 
when  the  applications  were  made.  Here,  then, 
through  unconscious  autosuggestion,  there  oc- 
curred motor  reaction  to  a  supposed  applica- 
tion of  electricity  even  though  by  reason  of 
her  ana3sthesia  the  patient  consciously  could 
not  perceive  the  application  of  the  electrode^ 
(Janet:  op.  cit.,  p.  27.) 

In  order  to  demonstrate  the  doubling  of  eon-^ 
sciousness  in  hysteria  Alfred  Binet  adduced 
some  interesting  experiments  upon  patients 
with  complete  anaesthesia  of  an  upper  extrem- 
ity. He  pricks  the  hand  a  certain  number  of 
times  and  then  asks  the  patient  what  number 
comes  into  his  mind.  Often  the  patient  gives 
the  same  number  as  that  of  the  pricks  he 
was  unable  to  feel.  To  vary  the  experiment 
some  object  may  be  placed  in  the  anaesthetic 
hand  and  then  the  patient  asked  to  name  the 
thing  of  which  he  is  thinking.  Having  screened" 
the  hand  Binet  passively  flexes  and  extends- 
one   of  the  fingers  a  number  of  times.      Fre- 


Disturbances  of  Sensory  Perception      73 

quently  he  finds  that  the  movements  automati- 
cally continue  a  few  times  after  he  ceases  im- 
parting the  passive  motion.  In  order  to  continue 
the  actions  of  flexion  and  extension  the  patient 
must  have  perceived  the  sensory  impressions — 
muscular  and  articular — produced  by  the  pas- 
sive movements.  Subconscious  perception  and 
recognition  accounts,  too,  for  the  fingers  grasp- 
ing in  the  correct  manner  such  objects  as  scis- 
sors or  a  pen  which  are  placed  in  the  anaes- 
thetic hand.  By  means  of  guiding  the  screened 
movements  of  the  pen  the  same  author  causes 
the  hand  to  write  a  familiar  name.  In  doing 
so  the  name  intentionally  is  misspelled.  Now, 
having  started  the  hand  to  rewrite  the  name 
the  writing  is  automatically  completed,  but 
often  the  mistake  is  corrected.  This  experi- 
ment shows  that  not  only  did  there  occur  sub- 
conscious perception  of  the  primarily  passive 
movements  but  that  some  kind  of  intelligence 
which  was  apart  from  the  consciousness  of  the 
patient  recognized  and  corrected  a  mistake  in 
orthography.  Finally,  becoming  accustomed  to 
automatic  writing  the  patient  writes  a  word 
which  has  been  traced  upon  the  back  of  his 
ansesthetic  hand.  (On  Double  Consciousness, 
1905.) 

By  proving  that,  in  spite  of  what  appears  to 
be  complete  anaesthesia,  patients  do  perceive  im- 
pressions arising  in  the  affected  region  the  term 
anaesthesia — T\ithout  feeling — ^is  shown  to  be  a 


74  Psychopathology  of  Hysteria 

misnomer.  Then,  are  all  patients  with  hysteric 
anassthesia  nothing  but  malingerers?  Success- 
fully to  simulate  a  condition  with  such  peculiar 
qualities  would  necessitate  that  the  individual  be 
exceedingly  clever  and  stoical  enough  to  with- 
stand pain  without  a  murmur.  However,  no 
person  who  is  simulating  with  a  definite  object  in 
view  would  expose  his  malingering  by  reacting  to 
experiments  in  the  manner  which  has  just  been 
de^scribed. 

Might  not  a  woman  simulate  anaesthesia  solely 
in  order  to  provoke  attention?  If  anyone  should 
simulate  the  symptom  with  no  other  apparent 
object  than  to  excite  interest  the  condition  could 
not  be  considered  malingering  in  the  sense  that 
this  term  is  commonly  employed,  but  the  rea- 
son for  the  simulation  alone  would  be  indicative 
of  one  of  the  mental  peculiarities  of  hysteria. 

It  is  safe  to  look  upon  hysteria  as  the  only 
condition — except  insanity — in  which  an  adult 
might  simulate  for  the  purpose  of  arousing  sym- 
pathy. But,  simulation  of  anaesthesia  by  a 
hysteric  is  rare,  and  enough  has  been  written  al- 
ready to  show  that  hysteric  disturbances  of 
sensory  perception  are  symptoms  over  which  the 
patient  has  not  any  control,  originating,  as  they 
do,  in  dissociation  of  consciousness. 

The  curious  qualities  of  hysteric  anesthesia 
can  be  interpreted  in  only  one  way.  It  is  only 
a  psychologic  explanation  which  is  adequately 
capable  of  accounting  for  the  fact  that  a  patient 


Disturbances  of  Sensory  Perception      75 

is  unaware  of  a  perception  whose  existence  can 
be  demonstrated.  Hysteric  anesthesia,  and 
other  similar  disturbances  of  perception,  can 
be  made  intelligible  by  assuming  that  while  sen- 
sory impressions  really  are  perceived  there  is 
lack  of  synthesis  of  the  percepts  with  conscious- 
ness. In  other  words,  there  is  deficiency  of  per- 
sonal perception,  or,  less  technically  to  express 
the  condition,  hysteric  anaesthesia,  as  indicated 
by  Lasegue  in  1864,  is  but  a  result  of  patholo- 
gic exaggeration  of  normal  absent-mindedness, 
personal  examples  of  which  each  of  us  can 
readily  recall.  It  is,  then,  only  the  exaggeration 
of  the  normal  peculiarity  of  the  human  mind 
which  permits  one  to  search  for  the  hat  which 
is  upon  his  head,  or  which  is  accountable  for  the 
fact  that  soldiers  who  have  been  wounded  often 
continue  to  fight  without  feeling  any  pain,  and, 
in  fact,  even  ignorant  of  the  wounds  which  they 
have  sustained. 

Hysteric  anaesthesia  might  be  compared,  also, 
with  the  field  of  attention  in  the  act  of  vision. 
One  whose  attention  is  concentrated  on  an  object 
in  any  portion  of  the  visual  field  may  not  con- 
sciously perceive  objects  in  any  other  portion  of 
the  field,  yet  experimentally  it  has  been  demon- 
strated that  under  these  conditions  there  has 
actually  occurred  subconscious  perception  of 
visual  impressions  in  the  field  peripheral  to  the 
fixation  point  of  attention. 


76  Psychopathology  of  Hysteria 

According  to  Janet,  hysteria  is  characterized 
by  retraction  of  the  field  of  consciousness  with 
the  consequence  that  the  patient  is  unable  to  at- 
tend to  the  many  impressions  which  are  con- 
stantly being  conveyed  to  the  brain  from  dif- 
ferent parts  of  the  body.  Certain  perceptions, 
therefore,  are  ignored,  and  this  primarily  volun- 
tary suppression  of  perceptions,  becoming  ha- 
bitual, results  in  the  production  of  ansesthesia, 
amaurosis,  etc. 

Freud  looks  upon  anaesthesia  and  other  symp- 
toms as  symbolic  representations  of  former  ex- 
periences which  have  been  forgotten — suppressed 
— because  of  their  unpleasant  nature.  This  ex- 
planation of  the  absence  of  personal  perception 
is  not,  however,  universally  applicable.  It  does 
not  explain,  for  instance,  why  anaesthesia  may 
appear  after  traumatism  of  which  the  patient  has 
a  most  vivid  recollection.  It  is  eminently  practi- 
cable in  those  cases  in  which  the  disease  has  de- 
veloped after  more  obvious  psychic  insults  whose 
memories  really  have  been  suppressed  from 
consciousness. 

Although  hysteric  angssthesia  does  not  usually 
cause  any  disturbance  of  the  motor  functions  of 
the  affected  part  there  may  occur  occasionally, 
in  a  profoundly  anaesthetic  member,  an  asso- 
ciated motor  disability  that  is  present  only  when 
the  patient's  eyes  are  closed,  or  when  they  are 
directed  away  from  the  part.  This  pseudo- 
paralysis, known  as  Lasegue's  syndrome,  is  appar- 


Disturbances  of  Sensory  Perception      11 

-ent  only  during  attempts  to  perform  consciously 
some  movement ;  automatic  and  lower  reflex  acts 
not  being  impaired.  When  a  part  is  the  seat  of 
total  hysteric  ana3sthesia  it  is  non-existent  to  the 
patient  unless  she  can  see  it,  or  feel  it  with  some 
other  member,  and  this  alone  is  quite  sufficient 
to  account  for  the  condition.  Such  an  explana- 
tion is  supported  by  the  fact  that  these  patients 
are  able,  with  the  assistance  of  visual  imagina- 
tion or  of  tactile  impressions,  to  carry  out  a 
movement,  and,  furthermore,  subconscious  move- 
ments are  not  affected.  Unless  originating  as  a 
psychologic  artefact — a  product  of  too  careful 
study  or  of  unconscious  suggestion  during 
medical  examinations — it  would  seem  that  the 
development  of  Lasegue's  syndrome  is,  to  say 
the  least,  most  improbable. 

The  mental  processes  of  sensory  perception 
have  been  divided  by  Ernest  Jones  into  two 
groups ;  the  first  of  which  comprises  those  pro- 
cesses dependent  upon  esthesic  impulses,  and 
the  second  group,  designated  auto-somatognos- 
tic,  embraces  the  memory  feelings  of  different 
parts  of  the  body.  It  is  by  reason  of  the  normal 
activity  of  memories  of  feelings  that  have  been 
experienced  in  the  past  that  enables  one  to 
recognize  not  only  that  a  sensory  percept  results 
from  a  stimulus  applied  to  a  certain  part  of 
the  body,  but  also  to  know  which  side  had  been 
stimulated.  And  it  is  by  association  with  these 
memories  that  a  sensory  percept  is  experienced 


78  Psychopathology  of  Hysteria 

with  the  warmth  that  implies  personal  percep- 
tion. Now,  according  to  the  same  author,  if 
the  esthesic  sensibilities — tactile,  pain,  coenes- 
thetic,  etc.— return  first,  during  recovery  from 
hysteric  anaesthesia,  there  results  impairment 
of  personal  perception  so  that  the  patient  de- 
scribes a  tactual  perception  as  having  been 
induced  by  a  sensory  impression  in  a  part  that 
does  not  belong  to  his  body,  or  the  perception 
is  referred  to  a  corresponding  point  on  the  con- 
tralateral member  whose  sensibility  is  normal. 
As  an  instance  of  the  former  Jones  w^rites  of  a 
patient  who  said:  ^'You  are  touching  the 
back  of  some  fore-finger  with  a  blunt  pin;  it 
isn't  my  finger  and  I  have  no  idea  where  it  is, 
but  it  causes  an  intensely  disagreeable  shudder 
to  run  all  up  one  side  of  me. ' ' 

Dyschiria,  or  difficulty  in  naming  the  side  of 
the  body  from  which  a  sensory  impression  has 
been  perceived,  is  due  to  loss  of  the  "chirognos- 
tic"  sense — the  feeling  of  sidedness.  Sensory 
dyschiria  is  divided  by  the  same  author  into 
achiria  when  the  patient  cannot  recognize  which 
side  of  the  body  has  been  stimulated,  though  the 
sensory  impression  was  perceived,  allochiria  when 
the  stimulus  is  referred  to  a  corresponding  point 
on  the  opposite  side  of  the  body,  and  synchiria 
when  a  stimulus  simultaneously  arouses  the 
feeling  of  a  sensation  at  corresponding  points 
of  each  side  of  the  body.  (The  Precise  Diag- 
nostic   Value    of    Allochiria,    Brain,    1907,    p^ 


Disturbances  of  Sensory  Perception      79 

490.  The  Significance  of  Phrictopathic  Sen- 
sation, Jour,  of  Nerv.  and  Ment.  Dis.,  1908,  p. 
427.  The  Dyschiric  Syndrome,  Jour,  of  Abn. 
Psych.,  vol.  4,  p.  311,  etc.) 

Like  Lasegue's  syndrome,  it  is  probable  that 
most  of  the  instances  of  dyschiria  were  the  pro- 
duct of  examinations  during  which  this  condi- 
tion was  sought.  When  by  reason  of  the  sug- 
gestive technique  of  the  examination  patients 
are  permitted  to  grasp  the  idea  that  it  is  pos- 
sible for  a  stimulus  to  be  incorrectly  localized 
allochiria  and  other  defects  in  tactual  orienta- 
tion not  infrequently  are  discovered.  Accord- 
ing to  the  usual  technique  the  patient's  hand, 
for  instance,  is  stimulated  and  then  she  is  asked 
first  if  she  felt  anything,  then  ivhich  hand  was 
touched.  I  venture  to  state  that  these  defects 
will  never  be  found  if,  instead  of  such  a  sug- 
gestive technique,  the  physician  casually  tells 
the  patient  that  after  closing  her  eyes  she  will 
perform  a  certain  act  when  her  right  hand  is 
touched,  and  a  different  one  when  the  left 
hand  is  stimulated. 

In  common  with  other  manifestations  anaes- 
thesia may  be  transferred  from  side  to  side, 
modified,  and  even  caused  to  disappear  by 
means  of  the  local  application  of  metals,  mag- 
nets, or  any  kind  of  apparatus,  provided  only 
that  the  patient  can  be  induced  to  anticipate 
any  of  these  results.  These  phenomena,  the 
consequence  of  expectant  attention  on  the  part 


80  Psychopathology  of  Hysteria 

of  the  patient  and  of  suggestion  on  that  of 
the  physician,  besides  being  additional  evidence 
of  the  psychic  nature  of  symptoms  of  hysteria, 
are  mentioned  in  order  further  to  indicate  how 
readily  one  can  misinterpret  these  manifesta- 
tions, and  how  natural  it  is  to  ascribe  curative 
virtues  to  drugs  and  to  other  therapeutic  means 
whose  beneficial  action  is  due  entirely  to  sug- 
gestion and  to  expectant  attention. 

On  account  of  ignoring  the  effects  of  sugges- 
tion many  papers  and  books  concerning  the 
curious  and  remarkable  therapeutic  effects  of 
local  application  of  metals,  magnets,  etc.,  were 
written  during  the  last  century.  In  fact, 
metallo-therapy  and  magneto-therapy  were 
practiced  as  late  as  1880  by  many  famous 
physicians  and  at  many  hospitals;  including  la 
Salpetriere.  Even  some  of  the  recent  text- 
books contain  descriptions  of  the  peculiar 
effects  of  applications  of  metals  or  of  magnets 
to  anaesthetic  or  paralyzed  members,  without 
however,  suggestion  being  recognized  as  the 
true  cause  of  these  modifications.  It  is  the 
same  principle  that  caused  the  vogue  of  Per- 
kin's  metallic  tractors,  electric  belts,  valerian, 
asafoetida,  and  the  like.  It  is  curious  that 
while  many  physicians  are  quite  willing  to 
grant  that  suggestion  is  capable  of  producing 
and  of  modifying  symptoms  of  hysteria  yet 
they  do  not  recognize  the  pathogenic  effects  of 
their  own  suggestive   examinations,   and  they 


Disturbances  of  Sensory  Perception      81 

accept  with  avidity  new  therapeutic  ag^ents 
whose  supposed  virtues,  in  the  treatment  of 
the  disease,  are  dependent  entirely  upon  sug- 
gestion. 

In  case  hysteric  anaesthesia  has  not  existed 
for  a  long  time,  and  provided  that  it  has  not 
been  made  the  subject  of  much  experimenta- 
tion, and  that  sensibility  is  not  examined 
repeatedly,  it  is  usually  an  easy  matter  to  cause 
the  condition  to  disappear.  Otherwise,  it  may 
continue  indefinitely  as  shovni  by  the  old 
Salpetriere  patients;  ones  that  have  served  as 
clinical  material  for  a  succession  of  authors. 
Before  proceeding,  it  is  advisable  perhaps  to 
state  that,  excluding  exceptional  cases  in  which 
the  diagnosis  is  obscure,  the  physician  is  not 
justified  in  creating  the  "stigmata;"  condi- 
tions which  may  persist  indefinitely  unless 
removed  promptly  by  suggestion.  Enough  has 
been  written  already  to  point  out  that  the  only 
diagnostic  significance  they  possess  is  the  in- 
creased suggestibility  which  they  imply. 

As  already  mentioned,  hysteric  disturbances 
of  sensibility  are  not  confined  to  the  tactile 
sense.  Besides  absence  of  conscious  percep- 
tion of  tactile  impressions  there  may  occur 
similar  perceptual  derangements  involving  the 
pain  sense — analgesia- — ,  the  temperature  sense 
— thermo-ansesthesia — ,  the  pressure,  muscle, 
vibratory,  and  electrical  senses.  Being  of 
great  importance,  "anaesthesia"  of  the  special 


82  Psychopathology  of  Hysteria 

senses  will  receive  consideration  in  a  separate 
chapter. 

Excepting  loss  of  the  muscle  sense — a  condi- 
tion whose  existence  is  incapable  of  being  con- 
ceived by  most  patients — a  part  which  is  the 
seat  of  hysteric  anaesthesia  is  usually  affected 
also  with  loss  of  the  pain,  temperature,  and 
perhaps  even  other,  senses.  Necessarily  this 
must  be  true,  for  patients  do  not  possess  knowl- 
edge of  the  anatomic  and  physiologic  differen- 
tiation of  sensibility,  and,  consequently,  a  part 
that  is  numb  must  be  numb  to  all  kinds  of 
stimuli. 

Rarely,  involvement  of  the  muscle  sense  may 
occur  independently  in  cases  of  profound 
anaesthesia,  but  it  may  be  found  more  fre- 
quently if  the  condition  is  sought,  for  then  the 
attention  of  the  patient  is  directed  to  the  pos- 
sibility of  the  occurrence  of  this  manifestation. 
As  compared  with  what  should  be  observed  in 
case  of  organic  loss  of  muscle  sense  the  hysteric 
variety  presents  some  characteristics  which,  to 
say  the  least,  are  peculiar.  Thus,  the  hysteric 
is  able  to  maintain  the  position  in  which  a  limb 
has  been  passively  placed  while  her  eyes  were 
closed,  yet,  as  in  two  patients  I  have  observed, 
she  asserts  that  she  does  not  even  know  where 
her  limb  is  located.  This  would  be  utterly  im- 
possible if  the  disturbance  were  organic  and 
advanced  to  such  a  degree.  Then,  too,  the 
hysteric  may  be  able,  without  the  assistance  of 


Disturbances  of  Sensory  Perception       83 

vision,  to  move  the  affected  extremity  without 
any  ataxia  becoming  apparent,  even  though  she 
is  unable  to  duplicate  the  position  in  which  the 
contralateral  and  normal  member  has  been 
placed.  Other  patients  who,  during  an  exami- 
nation, present  decided  hysteric  incoordination 
of  the  lower  extremities,  afterwards  walk 
around  without  exhibiting  ataxia. 

While  examining  a  hysteric  there  not  infre- 
quently develops  a  kind  of  static  ataxia,  but 
even  if  this  be  sufficient  to  cause  her  to  fall,  it 
does  not  seem  to  occasion  any  inconvenience, 
and  almost  invariably  it  can  be  caused  to  dis- 
appear if  the  physician  impresses  the  patient 
with  positive  assurances  of  her  ability  success- 
fully to  stand  with  the  eyes  closed.  It  will  be 
noticed,  too.  that  the  patients  who  present  this 
inoeuous  form  of  ataxia  are  often  the  ones  who 
complain  of  vertigo.  This  is  significant  be- 
cause the  vertigo  serves  as  a  basis  from  which, 
by  autosuggestion,  static  ataxia  is  developed. 

The  conclusion  to  be  drawn  from  study  of  the 
various  kinds  of  disturbances  of  sensory  percep- 
tion that  have  been  described  is  that  one  can  not 
be  too  careful  in  testing  for  the  purpose  of 
eliminating  possible  organic  disease,  because,  if 
the  patient  is  a  hysteric,  the  very  conditions  that 
are  sought  will  be  created  solely  by  reason  of 
unconscious  suggestion,  unless  the  technique  of 
examination  is  almost  perfect  in  its  freedom 
from  pathogenic  suggestion. 


84  Psychopathology  of  Hysteria 

Formerly,  the  discovery  of  hyperaesthetic 
areas  in  the  inframammary  and  ovarian  regions 
was  supposed  to  possess  considerable  diagnostic 
significance.  Clinical  experience  shows,  how- 
ever, that  if  pressure  is  made  in  any  part  of  the 
body  while  asking  the  patient  if  pain  is  pro- 
duced, areas  of  hypergesthesia  can  be  cre- 
ated without  further  suggestion  in  almost 
all  cases  of  hysteria,  and  wherever  one  desires. 
On  the  other  hand,  this  symptom  will  almost 
never  be  found  if  the  regions  supposed  to  be  the 
elective  seat  of  hyper^esthesia  be  pressed  upon 
while  the  patient's  attention  is  directed  else- 
where, or  if  the  pressure  be  made  without  hav- 
ing caused  the  patient  to  believe  that  pain  or 
any  other  unpleasant  sensation  is  expected. 

Inasmuch  as  it  was  customary,  and  for  obvious 
reasons,  to  regard  the  ovarian  and  the  inframam- 
mary regions  as  the  ones  in  which  hypersesthesia 
commonly  existed,  these  were  the  only  ones  which 
ordinarily  were  subjected  to  examination.  Con- 
sequently, hypersesthesia  in  these  regions  was 
supposed  to  be  valuable  evidence  in  favor  of  the 
diagnosis  hysteria.  Now,  we  can  interpret  this 
"stigma"  almost  invariably  to  be  the  conse- 
quence of  the  suggestive  manner  in  which  it  is 
sought. 

Wlieii  occurring  independently  of  examina- 
tions, quite  commonly  hyperassthesia  results  as 
the  peripheral  projection  of  hallucinatory  pain 
arising  from  a  fixed  belief  that  has  been  en- 


Disturbances  of  Sensory  Perception      85 

gendered — suggested — by  some  former  accident 
or  unpleasant  experience.  In  some  of  these 
cases  the  hj^peraesthesia  or  pain  has  been  caused 
to  continue  long  after  the  painful  effects  of  the 
trauma,  or  of  the  disease  process  from  which  it 
originated,  should  have  disappeared;  the  con- 
tinuation being  due  to  fixation  of  the  s\Tiiptom 
by  expectant  attention.  Following  an  operation 
for  appendicitis,  for  instance,  the  patient  may 
continue  to  complain  of  pain  or  of  hyperassthe- 
sia  around  j\IcBurney's  point.  If  pressure  be 
exerted  in  this  region  the  perception,  by  asso- 
ciation of  ideas  mtli  the  memory  complex  con- 
cerning the  former  appendicitis  and  the  op- 
eration, arouses  a  mental  representation  so  vivid 
as  to  cause  the  hallucination  of  pain.  That  the 
symptom  is  not  due  to  adhesions  or  to  some  other 
cause  of  actual  pain  can  be  demonstrated  by 
causing,  through  psychotherapeutic  means,  com- 
plete and  permanent  removal  of  the  pain. 

Syngesthesia  is  the  name  applied  to  that  phe- 
nomenon characterized  by  mental  representation 
of  a  perception  of  one  kind  of  sensation  in  conse- 
quence of  a  stimulus  to  a  totally  different  sen- 
sory system.  In  the  subdivision  of  synsesthesia 
known  as  audition  coloree  the  hearing  of  a  cer- 
tain name,  or  sound,  arouses  a  fixed  color  rep- 
resentation. The  various  kinds  of  syngesthesia 
are  due  to  associations  of  ideas  which  were 
usually  formed  in  infancy.  Suppose,  however, 
by  reason  of  the  same  process — association  of 


86  Psychopatlwlogy  of  Hysteria 

ideas — the  sight  of  a  knife  or  the  word  ''op- 
eration" should  provoke  hallucinatory  pain  be- 
cause these  stimuli  "touch"  the  repressed  com- 
plex of  a  surgical  operation:  then  this  analogue 
of  an  instance  of  normal  synesthesia  is  patholo- 
gic because  it  is  not  compatible  with  the  best  in- 
terests of  the  individual. 

In  the  absence  of  an  organic  cause  for  the 
symptom,  hysteric  pain  may  be  regarded  as  the 
hallucinatory  expression  of  a  subconscious  mem- 
ory of  pain.  Prince  compares  hysteric  pain  with 
the  power  of  mental  representation  possessed  by 
good  visual izers  and  auditives,  who  revive  with 
the  intensity  of  a  hallucination  the  visual  or  au- 
ditory memories  of  past  experiences.  He  consid- 
ers hysteric  pain  to  be  a  quasi-hallucination  due 
to  revival  of  memory  images  of  a  former  and 
actual  pain.  (Amer.  Syst.  of  Pract.  Med.,  p. 
628.) 

Hypersesthesia  and  pain  may  occur  also  in 
any  hysteric  patient  who  has  a  variety  of  symp- 
toms which  imply,  to  her,  a  disease  that  ordi- 
narily is  accompanied  with  pain  or  tender- 
ness. If  the  pain  is  located  in  the  breast  and 
is  associated  with  hysteric  oedema  it  is  pos- 
sible to  mistake  the  condition  for  tumor  of  the 
breast.  Ovarian  disease,  coxalgia,  and  other 
organic  diseases  may  be  mimicked  in  the  same 
manner.  Hysteric  pseudo-migrane  is  very  com- 
mon; perhaps  more  than  half  of  the  so-called 
eases  of  migrane  in  women  really  are  hysteric 


Disturbances  of  Sensory  Perception      87 

in  origin,  and,  therefore,  the  condition  has  no 
other  relation  to  true  migraine  than  its  super- 
ficial resemblance  to  this  disease. 

By  reason  of  the  psychic  nature  of  hysteria 
there  is  not  any  structure  in  which  organic  pain 
can  arise  that  is  not  capable  also  of  being  the 
seat  of  externalized  pain  of  psychic  origin.  At 
all  events  there  should  not  be  any  difficulty  in 
distinguishing  between  organic  pains  and  those 
due  to  hysteria. 

The  hysteric  often  smiles  pleasantly  while 
describing  the  severe  pain  with  which  she  is 
afflicted  and  though  her  suffering,  judging  from 
her  description,  is  so  intense  that  it  should  pros- 
trate her,  yet  it  does  not  seem  to  cause  any 
real  distress.  While  conversing  with  the  pa- 
tient one  frequently  gains  the  impression  that 
the  emotional  and  physical  reactions  are  exag- 
gerated, and,  upon  resorting  to  a  physical  ex- 
amination, careful  search  fails  to  reveal  any 
physical  cause  for  pain,  or  one  is  found  which 
is  insignificant  as  compared  mth  the  amount  of 
pain  of  which  the  patient  complains. 

Pressure  upon  the  alleged  painful  region  not 
only  may  provoke  an  exaggerated  expression 
of  distress  but  it  may  precipitate  some  one  of 
the  innumerable  kinds  of  hysteric  crisis.  Dur- 
ing distraction  of  the  patient  ^s  attention,  how- 
ever, the  same  procedure  may  be  repeated  with- 
out causing  any  evidence  of  pain  whatever. 
The  so-called   hysterogenic   zones   can  be  de- 


88  Psychopathology  of  Hysteria 

scribed  more  appropriately  in  connection  with 
the  attacks  of  hysteria. 

Painful  organic  conditions  of  the  chest  and 
abdomen  are  productive  of  a  characteristic  type 
of  disturbance  of  respiration;  the  rate  usually 
being  increased,  and  inspiration  being  superfi- 
cial and  repressed.  Hysteric  pain  referred  to 
the  same  regions  may  be  accompanied  by  in- 
creased frequency  of  respiration,  but,  instead 
of  being  shallow  and  interrupted  in  type,  in- 
spiration is  free  and  enormousl}^  increased  in 
depth ;  especially  when  pressure  is  applied  over 
the  seat  of  pain.  In  case  of  abdominal  pain  a 
valuable  differential  sign  is  afforded  by  the 
fact  that  if  we  press  upon  that  part  of  the  abdo- 
men which  the  hysteric  asserts  is  painful,  we 
notice  the  absence  of  the  protective  rigidity 
that  is  aroused  by  painful  organic  abdominal 
disease. 


CHAPTER  IV 

The  Disturbances   of  Sensory  Perception — The 
Special  Senses 

VISUAL  Perception.  Amaurosis,  an 
unusual  condition,  though  much 
less  uncommon  than  was  formerly 
supposed  to  be  the  case,  may  be 
unilateral  or  bilateral,  paroxysmal  or  con- 
stant, complete  or  incomplete — amhlyopia — ,  and 
it  may  persist  for  many  years  or  appear  only 
as  a  transitory  manifestation.  Usually  this 
special  type  of  psychic  anaesthesia  develops  in 
females,  and  the  unilateral  form  of  visual 
deficit  is  decidedly  more  common  than  bilateral 
amaurosis.  Amblyopias  are  encountered  much 
more  frequentlj^  than  amaurosis,  and,  like  anaes- 
thesia, they  may  be  either  autogenous  or  the 
result  of  suggestion  during  examination  of  the 
patient's  vision. 

Xot  a  few  of  the  reported  cases  of  monocular 
amaurosis  and  amblyopia  have  occurred  in 
association  with  homolateral  hemiansesthesia 
and  similar  unilateral  sensory  derangements. 
The  reason  for  this  is  apparent  when  one  stops 
to  consider  that,  in  the  minds  of  the  laity,  hemi- 
ansesthesia  should  include  all  of  the  senses  of 
one  lateral  half  of  the  body. 

When  amaurosis  occurs  independently  of  hemi- 
anesthesia the  cornea  and  the  skin  immediately 

89 


90  Psychopathology  of  Hysteria 

surrounding  the  eye  may  be  the  seat  of  anaes- 
thesia. This  may  be  explained  in  the  same 
manner  that  we  account  for  the  anomalous  bor- 
ders of  ordinary  anesthesia.  Just  as  the  layman 
thinks  in  popular  terms  of  arms,  forearms,  and 
legs,  so  does  he  think  of  the  eye  as  including 
vision,  the  eye  ball,  the  eyelids,  and  adjacent 
structures ;  the  popular  use  of  such  expressions  as 
"closing  of  the  eyes"  being  somewhat  indica- 
tive of  this  conception.  Accordingly,  in  asso- 
ciation with  psychic  amaurosis  what  is  more 
natural  than  the  occurrence  of  subjective 
angesthesia  of  the  cornea,  and  eye  lids? 

The  exciting  cause,  particularly  of  monocu- 
lar amaurosis,  often  is  found  to  be  some 
trauma,  rarely  other  than  trivial,  which  the 
patient  believed  capable  of  producing  blind- 
ness. For  instance,  in  one  of  Gradle's  cases 
hysteric  monocular  amaurosis  followed  an  in- 
jury adjacent  to,  but  not  involving,  the  af- 
fected eye.  (Jour,  of  the  A.  M.  A.,  April  24, 
1909,  p.  1308.) 

Like  the  production  of  other  symptoms  of 
hysteria  it  would  appear  that  anything  which 
merely  concentrates  the  patient's  attention 
upon  the  visual  function  is  sufficiently  sugges- 
tive to  result  in  amaurosis  or  amblyopia.  In 
two  of  my  ovni  cases  amaurosis  was  evidentlj^ 
caused  by  procedures  which  had  induced  con- 
centration of  the  patient's  attention  upon 
vision. 


The  Special  Senses  91 

Miss  M.,  aet.  23,  presented  typical  major 
symptoms  of  hysteria.  October  12,  1908,  a 
drop  of  tuberculin  solution  was  instilled  into 
her  right  eye,  and,  to  control  the  test,  a  drop 
of  saline  solution  was  placed  in  the  left  one. 
The  great  importance,  to  her,  of  the  results  of 
the  Wolff-Eissner  test  led  Miss  M.  frequently 
to  examine  her  eyes ;  in  fact,  there  was  aroused 
a  constant  state  of  expectant  attention  cen- 
tered upon  her  eyes  and  upon  vision.  The 
next  day,  though  both  eyes  appeared  to  be 
normal,  the  patient  complained  of  a  feeling  of 
irritation  in  the  left  one,  and  of  homolateral 
impairment  of  vision.  She  was  told,  then,  that 
the  tuberculin  had  been  instilled  only  into 
the  right  eye.  Complete  monocular  psychic 
amaurosis,  affecting  vision  with  the  right  eye, 
was  present  when  she  awakened  the  following 
morning.  Having  had  explained  to  her  the 
nature  of  the  blindness,  and  after  positive  as- 
surances that  her  vision  would  become  normal 
in  the  course  of  a  few  days,  the  symptom  was 
caused  to  disappear  promptly  without  necessi- 
tating recourse  to  other  procedures. 

In  the  case  of  Mabel  A.,  a  major  hysteric, 
aet.  12,  attacks  of  complete  bilateral  psychic 
amaurosis  developed  22  days  after  perimetric 
examination  and  without  any  other  probable 
cause  being  ascertainable.  The  prolonged  and 
repeated  examination  with  the  perimeter,  a 
quite  sufficient  cause  for  the  production  of  the 


92  Psychopatkology  of  Hysteria 

symptom,  so  concentrated  the  attention  of  the 
patient  upon  her  visual  function  that,  follow- 
ing a  not  uncommonly  extended  period  of 
meditation,  or  of  autosuggestion,  amaurosis  ap- 
peared. The  attacks  of  amaurosis,  each  of 
which  lasted  several  hours,  were  caused  to  dis- 
appear without  difficulty  by  means  of  sugges- 
tion during  the  hypnotic  state. 

The  shock  of  being  told  by  another  physi- 
cian that  her  fundi  showed  evidences  either  of 
iirt"emia  or  of  tuberculosis  ( !)  was  sufficient 
in  one  patient  to  provoke  bilateral  amblyopia 
of  high  degree.  After  the  elimination  of  pos- 
sible organic  causes  for  the  reduction  in  visual 
acuity  psychotherapy  was  effectual  in  causing 
speedy  return  of  vision  to  normal,  and,  it  is 
needless  to  say,  ophthalmologic  examination 
resulted  in  negative  findings. 

Another  instance  of  an  emotional  cause  is 
worthy  of  mention.  A  young  lady  was  much 
agitated  in  anticipation  of  singing  a  solo  in 
church.  When  the  time  arrived  her  vision  be- 
came indistinct  and  the  congregation  seemed 
to  disappear  from  view.  These  symptoms 
might  appear  in  anyone  and  without  further 
difficulty  being  experienced.  In  the  ease  of 
actors  with  stage  fright  often  the  audience  ap- 
pears to  be  blotted  out,  but  this  systematized 
amaurosis  is  only  a  temporary  manifestation  of 
a  reaction  of  defense.  As  stage  fright  is 
primarily  due  to  fear  of  the  audience  suppres- 


The  Special  Senses  93 

sion  of  the  visual  image  of  this  body  must  be  a 
conservative  process.  At  all  events,  the  young 
lady  was  subject  to  hysteria,  and,  consequently, 
the  temporary  emotional  blurring  of  vision  be- 
came elaborated  into  complete  bilateral 
amaurosis.  It  was  necessary  to  lead  her  home, 
and  the  symptom  persisted  for  three  days, 
when  spontaneous  recovery  of  vision  occurred. 
Following  this  experience  any  decided  excite- 
ment was  sufficient  to  provoke  a  similar  at- 
tack. 

Recurrence  of  hysteric  accidents  is  common. 
It  seems  that  any  emotional  disturbance  tends 
to  cause  repetition  of  former  pathologic  reac- 
tions providing  that  another  kind  of  reaction 
is  not  casually  suggested  upon  the  patient. 
Moreover,  transitory  attacks  of  amaurosis  are 
quite  common ;  it  is  only  the  more  permanent 
ones  which  are  unusual. 

As  all  the  possible  accidents  of  hysteria  are 
potential  in  a  given  case  and  as  each  requires 
only  an  adequate  exciting  cause  to  render  it 
actual,  so  in  these  four  cases  the  diagnostic 
tests  and  the  emotional  disturbances  were  quite 
sufficient  to  determine  the  genesis  of  amaurosis. 
Naturally,  a  factor  which  is  capable  of  acting 
as  the  exciting  cause  of  a  symptom  in  one 
hysteric  individual  is  of  negligible  etiologic 
importance  in  others ;  the  harmlessness  of  the 
factor  or  the  induction  of  pathologic  conse- 
quences depending  entirely  upon  the  personal 
equation. 


94  Psychopathology  of  Hysteria 

One  of  the  symptoms  of  hysteria  is  the  ten- 
dency, exaggerated  above  the  normal,  towards 
interference  with  the  perfect  accomplishment 
of  volitional  acts,  and  more  particularly  of 
more  or  less  automatic  acts,  when  the  patient's 
attention  is  directed  to  their  performance.  For 
this  reason,  during  examination  of  visual  acu- 
ity, amblyopia  may  often  be  noticed  in  the  same 
manner  that  dyamometric  examination  may  ap- 
pear to  indicate  that  the  patient's  gripping 
power  is  greatly  diminished.  In  either  case  the 
condition  is  brought  about  by  the  tests  and 
usually  it  disappears  promptly  with  the  con- 
clusion of  the  examination.  These  subjective 
and  temporary  amblyopias  are  well  known, 
and,  in  testing  the  visual  acuity  of  hysteric 
patients,  every  ophthalmologist  employs  sug- 
gestion, whether  unconsciously  or  intention- 
ally, in  the  effort  to  reassure  the  patient  and  to 
induce  her  to  read  the  letters  of  just  one  more 
line  lower  down  on  the  test  card.  It  is  not  im- 
possible, too,  that  tests  of  visual  acuity  may 
occasion  more  persistent  amblyopia  or  amaurosis 
just  as  perimetric  examination  of  Mabel  A. 
eventuated  in  the  production  of  this  symptom. 

Prince  has  written  of  a  patient  whose  peculiar 
kind  of  amblyopia  may  have  been  produced 
by  an  examination  of  vision.  The  patient  had 
always  believed  that  his  vision  was  good  until 
he  was  examined  to  determine  his  fitness  for 
appointment  to  the  Boston  police  force.    As  the 


The  Special  Senses  95 

examination  showed  defective  visual  acuity, 
each  eye  being  tested  separately,  he  was  reject- 
ed. Subsequently,  he  was  examined  by  Dr. 
Putnam  and  Dr.  Prince  who  found  that  while 
binocular  vision  was  20/15  monocular  fixation 
reduced  his  vision  to  17/100  with  the  left  eye, 
and  to  17/70  with  the  right  one.  (Plysterical 
Monocular  Amblyopia  Coexisting  with  Normal 
Binocular  Vision,  Amer.  Jour,  of  the  Med. 
Sciences,  Feb.  1897). 

Even  a  distressing  sight  may  cause  amauro- 
sis. Great  excitement  normally  may  bring 
about  a  temporary  and  more  or  less  complete 
inhibition  of  vision.  In  such  cases  the  individ- 
ual asserts  that  everything  became  dark,  or 
that  he  acted  without  being  able  to  see  what 
he  was  doing.  When  one  witnesses  a  distress- 
ing or  revolting  scene,  there  is  a  tendency  to 
shut  out  the  view  by  closing  the  eyes,  or  by 
clapping  the  hands  over  them.  Consequently, 
when  hysteric  amaurosis  develops  after  such 
an  exposure^  the  condition  seems  to  be  but  the 
psychic  elaboration  of  this  normal  reaction  of 
defense.  And  the  dissociation  of  visual  per- 
cepts from  consciousness  once  having  occurred, 
the  symptom,  in  a  hysteric,  would  tend  to  per- 
sist indefinitely.  An  excellent  instance  of  this 
mode  of  genesis  is  afforded  by  a  case  which  was 
reported  by  H.  Gradle,  who  writes:  *^The 
patient,  hitherto  in  good  health,  had  had  a 
severe  shock  to   her  feelings,     .     .     .     ,   and, 


96  Psychopathology  of  Hysteria 

clapping  her  hands  to  her  eyes  to  shut  out  the 
sight,  found  herself  absolutely  blind/'  The 
next  day,  suggestion,  reinforced  with  mild 
faradism,  caused  the  return  of  conscious 
perception  of  visual  impressions.     (Gradle:  op. 

cit.). 

In  the  more  pure  forms  of  hysteria  the  pres- 
ence of  amaurosis  may  not  annoy  the  patient 
nor  cause  her  to  be  alarmed.  In  fact,  complete 
bilateral  amaurosis  may  not  cause  any  in- 
convenience in  some  cases,  and,  in  spite  of  the 
visual  loss,  the  patient  may  contrive  to  go 
about  as  usual ;  though  exhibiting,  perhaps,  the 
uncertain  actions  of  organic  blindness.  Be- 
cause of  its  psychic  nature,  and  in  contradistinc- 
tion to  most  varieties  of  organic  blindness,  the 
reflexes  of  the  iris  are  unimpaired,  with  but 
few  exceptions,  and  ophthalmologic  examina- 
tion fails  to  reveal  any  pathologic  changes.  It 
scarcely  need  be  mentioned  that  the  suddenly 
appearing  ambloypias  due  to  toxaemias  and  to 
exposure  to  intense  light,  may  not  be  accom- 
panied with  fundus  changes,  and,  therefore, 
these  possibilities  must  be  excluded  before 
making  a  diagnosis.  Of  some  diagnostic  impor- 
tance is  the  discovery  of  corneal  anaesthesia 
and  of  a  ring  of  anaesthesia  surrounding  the 
eyes. 

While  reading  a  book  the  attention  of  a  normal 
person  may  become  concentrated  upon  some  ex- 
traneous idea.     Subconsciously  he  continues  to 


The  Special  Senses  97 

read;  but  when  his  attention  returns  to  the 
book  he  finds  that  he  is  ignorant  of  all  that  he 
had  read  while  his  attention  was  diverted.  Now, 
we  know  that  experiments  performed  under  sim- 
ilar circumstances  have  been  successful  in  caus- 
ing the  subject  to  reproduce  the  memories  of 
events  which  occurred  during  distraction  of  at- 
tention, and  we  are  justified,  on  these  grounds, 
in  asserting  positively  that  in  the  above  instance 
it  would  be  possible  to  effect  reproduction  of  the 
subject  matter  which  was  read  while  the  indivi- 
dual was  pursuing  the  extraneous  line  of 
thought.  During  distraction  of  his  attention  the 
person  was  not  blind ;  he  continued  to  read  auto- 
matically but  the  visual  perceptions  were  not 
synthetized  wdth  consciousness.  Hysteric  amau- 
rosis is  identical  in  character.  The  visual  ap- 
paratus of  the  hysteric  is  normal,  and  subcon- 
sciously visual  perception  occurs,  as  can  be 
demonstrated  readily,  only  she  is  not  attending 
to  these  perceptions.  They  remain  subconscious  ; 
they  are  not  sjTithetized  with  consciousness.  In 
her  case  the  mental  blindness  is  due  to  dominant 
belief  in  her  inability  to  see,  and  just  as  soon  as 
she  can  be  induced  sincerely  to  expect  disap- 
pearance of  her  blindness  it  wdll  disappear. 

Let  us  adduce  another  common  example  of 
the  psychic  blindness  of  absent-mindedness. 
While  walking  along  the  street  a  person  whose 
attention  is  concentrated  upon  some  problem 
passes  his  friends,  perhaps  looking  directly  at 


98  Psychopathology  of  Hysteria 

them,  yet  fails  to  respond  to  their  salutations. 
Subconsciously  he  sees  them,  but  there  is  lack  of 
that  personal  perception  which  is  requisite  for 
conscious  recognition.  In  the  same  manner  he 
fails  consciously  to  perceive  the  many  visual  im- 
pressions which  arise,  and  he  may  even  walk  past 
his  destination. 

By  means  of  post-hypnotic  suggestion  one  is 
able  to  create  a  psychic  blindness  which  will  per- 
sist after  the  hypnotic  state  has  been  caused  to 
disappear.  When  produced  in  this  manner  psy- 
chic amaurosis  possesses  all  the  characteristics 
of  that  due  to  hysteria,  and  in  itself  is  indistin- 
guishable from  hysteric  blindness.  With  the  as- 
sistance of  hypnotic  suggestion,  or  of  post-hyp- 
notic suggestion,  one  can  cure  hysteric  amauro- 
sis. These  facts,  together  with  the  known  influ- 
ence of  extra  hypnotic  suggestion  in  causing, 
modifying,  and  in  curing  hysteric  blindness, 
seem  to  be  sufficient  grounds  for  the  proposi- 
tion that  hysteric  amaurosis,  in  common  with 
other  symptoms  of  the  disease,  is  always  the 
effect  of  expectant  attention,  suggestion,  or 
whatever  one  wishes  to  call  the  process.  As 
such,  the  condition  is  really  the  same  as  that 
produced  with  hypnosis,  from  which  it  differs 
only  in  its  mode  of  production;  the  first  being 
due  to  autosuggestion  that  has  been  induced 
by  some  external  stimulus,  or  suggestion,  that 
even  may  have  proceeded  accidentally  from  a 
second  person,  and  the  other  being  the  direct 


The  Special  Senses  99 

eiffect  of  intentional  suggestion  by  another. 
Otherwise,  the  nature  and  mode  of  genesis  of 
inorganic  psychic  blindness  have  never  been 
explained  in  a  manner  that  is  compatible  with 
what  now  is  known  of  its  qualities  as  revealed 
by  experimentation. 

Hysteric  monocular  amaurosis  might  be  com- 
pared with  the  habitual  suppression  of  the 
secondary  image  of  diplopia  in  cases  of  strabis- 
mus. A  more  accurate  comparison  is  afforded 
by  the  voluntary  suppression  of  visual  impres- 
sions arising  in  one  eye,  when,  with  the  other, 
the  pathologist  is  intently  studying  some 
specimen  with  the  microscope. 

Even  more  interesting  is  hysteric  system- 
atized amaurosis,  a  condition  in  which  lack  of 
conscious  perception  of  visual  impressions  is 
confined  to  one  or  more  kinds  of  objects ;  vision 
otherwise  being  normal.  This  symptom,  too, 
is  but  the  pathologic  exaggeration  of  what  is 
a  normal  peculiarity.  The  foUomng  citation 
from  Jastrow'of  a  normal  instance  of  system- 
atized psychic  amaurosis  and  anesthesia  serves 
well  to  introduce  the  subject: 

"A  business  man  living  in  the  suburbs,  as  he 
entered  the  train  upon  his  homeward  journey, 
reflected  upon  the  threatening  aspect  of  the 
sky,  and  considered  the  chances  of  finding  his 
carriage  awaiting  him  at  the  station,  in  case  the 
impending  rain  came  on.  His  hopes  were 
doomed   to    disappointment;   and   he   resigned 


100  Psych opathology  of  B.ysteria 

himself  to  a  wet  walk  home.  As  the  downpour 
became  heavier,  he  more  keenly  regretted  his 
wavering  hesitation  in  the  morning  in  regard  to 
taking  an  -umbrella.  When  at  length  he  pre- 
sented himself  dripping  at  his  door,  he  was 
greeted  with  shouts  of  derision  at  his  plight; 
for  tucked  under  his  arm  was  the  umbrella, 
unopened,  unperceived.  So  convinced  had  he 
been  that  he  had  neglected  to  provide  himself 
with  this  protection,  that  the  repeated  solicita- 
tions to  his  senses  offered  by  the  presence  of 
that  object  passed  unheeded.  Doubtless,  in  the 
course  of  his  walk,  the  umbrella  had  fallen  within 
the  range  of  his  vision;  and  certainly  his  arm 
had  sufficiently  attended  to  the  feelings  resulting 
from  the  carrying  of  the  article  to  prevent  its 
being  dropped.  To  these  appeals  to  see  and  feel 
and  recognize  did  his  mental  prepossession  ren- 
der him  blind  and  insensible.  Had  any  passer- 
by broken  through  his  "absent"  spell  and 
pointed  out  his  neglected  opportunities,  he  would 
at  once,  and  with  some  surprise  and  amusement, 
have  seen  and  felt  and  consciously  used  what  in 
his  reflections  he  repeatedly  longed  for:  in  this 
last  consideration  lies  the  normality  of  the  ex- 
perience."    (The  Subconscious,  1906,  p.  306.) 

Now,  let  us  consider  a  pathologic  instance ;  one 
described  by  Morton  Prince  in  his  report  of  the 
Beauchamp  case  of  multiple  personality.  One  of 
the  alternating  personalities  had  lost  one  of  ^liss 
Beauchamp 's  rings.  In  order  to  insure  the  safety 


The  Special .  Senses  101 

of  the  other  two  a  second  personality  had  strung 
them  on  a  ribbon  about  her  neck.  Believing 
that  all  the  rings  had  been  lost  Miss  B,  could 
neither  see  nor  feel  the  remaining  two.  Even 
when  the  rings  were  struck  together  she  was 
unable  to  hear  the  resulting  click. 

In  these  two  cases,  the  one  normal  and  the 
other  pathologic,  we  have  to  deal  with  lack  of 
sjmthesis  with  consciousness  of  all  kinds  of  sen- 
sory perceptions  arising  from  certain  objects — 
an  umbrella  in  the  first  instance,  and  a  ribbon 
and  two  rings  in  the  second  one.  The  deficit, 
therefore,  is  systematized  and  it  involves  each 
sense  that  is  stimulated  by  these  objects.  In  other 
words,  owing  to  a  firm  conviction  the  umbrella, 
ribbon,  and  rings  had  ceased  to  exist  as  far  as 
consciousness,  only,  of  the  various  perceptions  of 
each  of  these  objects  was  concerned.  Excluding 
consciousness  each  of  these  objects  was  perceived. 
Otherwise,  as  Jastrow  remarks,  how  could  the 
man  have  carried  his  umbrella?  And  in  Miss 
B.'s  case  a  second  personality  had  actually  sus- 
pended the  rings  from  her  neck.  In  the  normal 
instance  the  business  man  was  dominated  by  the 
con"\iction  that  he  had  left  his  umbrella  at  home 
with  the  consequence  that  all  kinds  of  percep- 
tions arising  from  the  umbrella  failed  to  be 
synthetized  wdth  consciousness.  In  the  same  way 
Miss  B.  was  dominated  by  the  belief  that  her 
rings  were  lost. 

Suppose,  now,  that  a  hypnotic  subject  be  given 


102  Psychopathology  of  Hysteria 

the  suggestion  that  a  third  person,  C,  has  left 
the  room,  and  that  only  he  and  the  one  who 
induced  hypnosis  remain.  After  dissipating  the 
hypnotic  condition  it  will  be  found  that  the  sub- 
ject exhibits  a  systematized  lack  of  conscious 
perception  of  all  kinds  of  sensory  impressions 
aroused  by  C,  and  the  resulting  condition  re- 
sembles that  of  the  business  man  and  of  Miss 
Beauchamp.  Only  in  this  case  the  conviction  is 
deliberately  suggested  upon  the  subject  by  his 
hypnotizer  while  in  the  other  instances  it  arose 
spontaneously. 

The  various  kinds  of  systematized  deficiency 
of  personal  perception  have  been  designated 
negative  hallucinations.  Though  convenient, 
this  term,  originated  by  Bernheim,  has  been  con- 
sidered inappropriate.  More  objectionable  are 
descriptions  in  which  the  lack  of  conscious  per- 
ception of  various  kinds  of  sensory  impressions 
is  said  to  be  due  to  dissociation  of  these  percepts 
from  consciousness.  In  order  that  percepts  can 
be  dissociated  antecedent  synthesis  must  have 
occurred,  and  if  dissociation  took  place  after 
synthesis,  then  the  resulting  condition  would  be 
amnesia  instead  of  a  disturbance  of  perception. 

Diagnosis  of  Binocular  Hysteric  Amau- 
rosis. Without  the  use  of  psychic  means  it 
may  be  difficult,  indeed,  to  exclude  organic 
blindness.  With  the  assistance  of  hypnotism 
one  may  be  able  to  make  a  positive  diag- 
nosis of  hysteric  amaurosis  by  means  of  demon- 


The  Special  Senses  103 

strating  the  existence  of  unconscious  vision. 
For  the  patient,  while  in  the  hypnotic  state,  per- 
haps can  be  caused  consciously  to  see  as  well  as 
before  the  onset  of  the  symptom,  and,  in  addi- 
tion, he  may  be  induced  to  state  the  name  of  an 
object  which  had  been  held  before  his  eyes  pre- 
"sdous  to  hypnosigenesis. 

Excluding  the  application  of  hypnosis  as  a 
diagnostic  means  there  are  other  tests  which  may 
not  be  so  successful.  A  simple  one  is  to  have 
the  patient  look  at  an  open  book.  Normally 
there  is  an  irresistible  tendency  for  the  eyes  to 
traverse  the  page,  and  if  these  ocular  movements 
occur  with  the  jjatient  one  is  justified  in  pre- 
suming that  some  kind  of  vision  exists. 

By  means  of  having  the  amblyopic  patient 
write  automatically  Binet  succeeds  in  demon- 
strating subconscious  perception  of  letters  which 
are  too  small  for  the  patient  consciously  to  per- 
ceive; and  the  writing  of  these  letters  proceeds 
while  the  patient  reiterates  his  inability  to  recog- 
nize them.  (On  Double  Consciousness,  1905,  p. 
32.) 

With  the  assistance  of  the  method  of  guessing 
it  is  possible,  sometimes,  to  secure  positive  results 
in  cases  of  hysteric  amblyopia.  Suppose  we  tell 
a  patient  whose  visual  acuity  is  10/70  that  we 
know  she  is  unable  to  read  the  smaller  letters 
two  lines  lower  down  on  the  test  card,  but  that 
we  desire  her  simply  to  make  rough  guesses  of 
these  letters  as  we  point  to  them.      Often  tbe 


104  Psychoxjathology  of  Hysteria 

guesses  are  correct,  just  as  in  case  of  anaesthesia 
the  number  that  flashes  into  the  patient's  mind 
after  we  have  touched  the  anassthetic  region  a 
certain  number  of  times  is  the  same  as  the  num- 
ber of  tactile  stimuli.  In  either  case  the  patient 
declares  that  she  does  not  see  the  letters  or  that 
she  has  not  perceived  any  sensations  in  the 
affected  region. 

Naturally,  it  may  be  possible  to  improve 
visual  acuity  by  employing  suggestion — even 
without  induction  of  the  hypnotic  state.  "When 
resort  is  had  to  this  kind  of  suggestion  it  is 
important  that  the  patient  should  not  become 
aware  of  its  use,  and,  therefore,  we  must  dis- 
guise the  suggestions.  For  example,  after 
noting  the  patient's  visual  acuity,  we  tell  her 
that  different  test  lenses  are  to  be  tried  in  order 
to  determine  which  improves  her  vision  the 
most.  Now,  by  employing  plain  glasses  while 
making  free  use  of  suggestion,  it  may  be  noticed 
that  vision  is  materially  improved. 

Diagnosis  of  Monocular  Hysteric  Amau- 
rosis. As  a  layman  is  ignorant  of  the  physi- 
ology of  the  visual  mechanism,  unilateral  psychic 
blindness,  whose  character  is  founded  solely 
upon  his  conceptions  of  vision,  necessarily  must 
present  some  very  curious  physiological  incon- 
sistencies when  the  condition  is  subjected  to- 
various  tests. 

In  the  study  of  patients  with  hysteric  monocu- 
lar amaurosis   even   more   apparent   than   with 


The  Special  Senses  105 

other  symptoms  of  the  disease,  is  the  fact  that 
the  results  of  experimentation  are  determined 
almost  entirely  by  the  patient's  conception  of  the 
disturbance  with  which  he  is  afflicted.  He  is 
blind  in  one  eye  only  because  he  is  firmly  con- 
vinced that  such  is  the  case.  Any  test  which  is 
adopted  for  the  purpose  of  demonstrating  vision 
in  the  amaurotic  eye  and  whose  significance  is  not 
appreciated  by  the  patient  will  succeed,  then, 
for  the  reason  that  it  does  not  conflict  with  his 
belief.  We  should  be  able,  therefore,  to  differ- 
entiate readily  this  visual  disturbance  from 
organic  blindness  of  one  eye.  The  differentia- 
tion is  rendered  still  more  simple  by  reason  of 
the  number  of  excellent  tests  to  which  we  can 
resort. 

In  the  presence  of  binocular  single  vision 
diplopia  occurs  when  one  eyeball  is  displaced 
by  pressure.  The  same  effect  may  be  produced 
more  accurately  and  less  rudely  if  we  take  ad- 
vantage of  the  principles  of  refraction  and 
place  a  prism  before  one  eye.  In  case  of  or- 
ganic monocular  amaurosis  both  displacement 
of  one  eyeball  and  the  use  of  a  prism  before 
either  eye  must  necessarily  fail  to  produce 
reduplication  of  the  image.  Consequently,  if  a 
patient  with  unilateral  blindness  can  be  caused 
to  experience  diplopia  by  either  of  these  means 
the  existence  of  binocular  vision  is  proven — 
the  blindness  is  psychic.  It  is  possible  that  the 
test  may  fail  because  of  lack  of  synthesis  -with 


106  Psychopathology  of  Hysteria 

consciousness  of  the  perception  of  the  image 
which  is  on  the  same  side  as  the  amaurotic  eye. 
Or,  when  the  prism  is  used,  the  two  images  may 
become  fused  if  the  ocular  muscles  are  strong 
enough  to  counteract  the  refractive  effects  of 
the  prism. 

A  test  has  been  described  by  Prince  that  does 
not  require  any  apparatus  but  which  necessi- 
tates care  in  its  application.  While  the  patient 
is  reading,  a  pencil  is  slipped  before  the  normal 
eye.  If  the  blindness  is  organic,  one  or  more 
words,  being  obscured  by  the  pencil,  are  not 
seen  by  the  patient.  If  the  condition  is  hysteric 
the  patient  may  continue  to  read  without  skip- 
ping any  words,  thus  demonstrating  the  per- 
ception of  visual  impressions  which  could  have 
originated  only  in  the  blind  eye.  One  must  be 
careful  to  hold  the  pencil  between  the  normal 
eye  and  the  printed  page  and  to  hold  it  still. 
Likewise  the  patient's  head  must  not  have 
moved  during  the  test.  Like  other  tests  this 
one  will  fail  if  the  patient  becomes  aware  of 
its  full  significance.  To  render  its  performance 
less  obvious  artifice  may  be  employed.  For 
instance,  one  may  disguise  the  test  by  saying: 
**When  I  raise  this  pencil  continue  to  read,  but 
do  so  more  rapidly."  Then,  apparently  as  an 
accident,  the  pencil  is  raised  high  enough  to  be 
in  the  visual  axis  of  the  normal  eye. 

Another  ^experiment  whose  application  is 
easy,  but  which  may  not  yield  positive  results, 


The  Special  Senses  107 

is  that  of  Pitres:  Even  though  a  screen — a 
blotter  for  instance — is  held  vertically  between 
the  patient's  eyes  and  at  right  angles  against 
his  face  he  may  be  able  to  read  from  a  book 
in  spite  of  the  fact  that  one  lateral  half  of  the 
page  can  be  seen  only  with  the  amaurotic  eye. 
If  the  screen  is  not  held  perpendicular  to  the 
center   of   the   page   the   results    are   vitiated. 

Monocular  amaurosis  must  be  psychic  if  the 
patient,  when  looking  through  a  stereoscope, 
acknowledges  that  the  picture  stands  out  in 
relief,  because  the  successful  use  of  this  con- 
trivance requires  binocular  single  vision.  Be- 
sides these  simple  measures,  tests  dependent 
upon  hypnosis,  and  similar  to  those  employed 
in  detection  of  hysteric  binocular  amaui'osis, 
can  be  applied  with  positive  results  in  many 
cases. 

With  the  assistance  of  special  apparatus  suc- 
cessful results  are  more  apt  to  be  secured. 
Stoeber's  ingenious  device  comprises  a  pair  of 
spectacles  containing  one  red  and  one  green 
glass,  and  an  object  consisting  of  a  printed 
word,  of  which  the  letters  are  alternately  red 
and  green  upon  a  black  background.  When  a 
patient  with  organic  blindness  fixes  the  object 
through  these  glasses  he  can  read  only  those 
letters  whose  color  is  the  same  as  that  of  the 
glass  which  covers  the  normal  eye.  If  a  pa- 
tient is  able  to  read  the  whole  word  then  his 


108  PsychopatJiology  of  Hysteria 

visual  defect  either  is  due  to  hysteria  or  it  is 
feigned. 

When  the  box  of  Flees  is  used  what  is  seen 
with  one  eye  appears  to  have  been  seen  with 
the  other,  so  that  the  hysteric  reports  having 
observed  either  both  objects  or  only  the  one 
•which,  in  reality,  was  seen  with  the  amaurotic 
eye.  The  malingerer  asserts  that  he  noticed 
but  one  object,  and  he  indicates  the  one  which 
we  know  could  have  been  seen  only  with  the 
eye  which  he  affirms  is  blind.  While  the  indi- 
vidual with  organic  monocular  amaurosis  re- 
ports having  observed  an  object  which,  to  his 
surprise,  appeared  to  have  been  seen  with  his 
blind  eye. 

Unfortunately,  the  results  of  these  experi- 
ments, except  those  dependent  upon  hypnosis, 
may  be  the  same  as  the  results  obtained  with 
malingerers.  As  far  as  the  tests  themselves  are 
concerned  there  may  not  be  any  way  of  differ- 
entiating the  two  conditions  and  the  diagno- 
sis may  depend  entirely  upon  associated  symp- 
toms and  upon  the  experience  of  the  examiner. 
In  commenting  upon  this  diagnostic  difficulty 
H.  Gradle  writes:  "The  distinction  between 
hysteric — or  let  us  say  psychic — blindness  and 
wilful  simulation  can  not  be  based  upon  objec- 
tive findings.  They  would  be  the  same  in 
both  cases.  We  must  base  our  judgment  on  a 
psychologic  analysis  of  the  patient's  mind  and 
object." 


The  Special  Senses  109 

If  the  utmost  care  is  not  exercised  in  making 
the  tests  the  answers  of  a  clever  malingerer,  or 
of  a  simulating  hysteric,  may  be  the  same  as 
those  of  a  patient  with  organic  monocular 
amaurosis.  In  either  case  the  subject  may  be 
enabled  to  do  this  if  he  has  the  opportunity 
furtively  to  close  the  supposedly  blind  eye  and 
thus  to  acquire  information  concerning  what 
should  be  seen  were  his  feigned  symptom  real. 
Or.  if  intelligent,  he  may  be  able  to  grasp  the 
significance  of  certain  of  the  tests.  As  a 
hypnotized  malingerer  ordinarily  would  not 
acknowledge  that  previous  to  the  induction  of 
hypnosis  he  had  seen  an  object  with  his  "blind" 
eye  such  a  test  would  be  useful;  unless  we 
accept  as  true  the  fallacy  that  a  hypnotized 
person  always  must  tell  the  truth. 

The  results,  too,  of  the  tests  that  have  been 
described  may  appear  positively  to  prove  that 
hysteric  unilateral  blindness  is  only  a  feigned 
symptom !  But  how  can  we  account  for  those 
cases  in  which  the  condition  persists  for  years 
in  patients  who  do  not  have  any  motive  for 
simulation,  or  who  have  excellent  reasons  for 
desiring  that  their  A^sion  should  be  normal? 
For  instance.  Prince's  amblyopic  patient  had 
gone  to  much  trouble  in  his  attempt  to  qualify 
for  appointment  to  the  police  force.  As  he  de- 
sired this  appointment  it  was  not  to  his  inter- 
est to  simulate  defective  vision.  Yet  the  tests 
seemed  to   indicate   that   he   was   deliberately 


110  Psychopathology  of  Hysteria 

malingering;  provided  that  one  disregards  the 
fact  that  the  same  results  could  be  obtained  in 
hysteria.  This  patient  had  perfect  binocular 
vision  but  each  eye  separately  was  amblyopic. 
A  prism  having  been  slipped  before  either  eye 
during  binocular  fixation  amblyopia  developed 
at  once.  Novir,  the  patient  once  having  reacted 
in  this  manner  the  same  results  were  obtained 
when  two  prisms  were  placed  together  so  as  to 
counteract  each  other  and  then  held  before  his 
eye.  One  who  failed  to  consider  the  patho- 
genic influence  of  belief  would  conclude  at  once 
that  this  patient  was  a  malingerer. 

According  to  de  Schweinitz  hysteric  amauro- 
sis may  last  even  as  long  as  ten  years,  though 
vision  has  ultimately  returned  in  all  recorded 
cases.  Wlien  the  patient  comes  under  treat- 
ment before  the  condition  has  had  time  to  be- 
come fixed,  removal  of  the  symptom  is  com- 
paratively easy. 

In  addition  to  its  diagnostic  value,  hypnotic 
suggestion  possesses  great  therapeutic  efficiency. 
Even  though  the  patient  be  not  hypnotized  syn- 
thesis of  the  visual  function  with  consciousness 
possibly  may  be  effected  without  difficulty  by 
means  of  suggestion.  In  case  suggestion  is  em- 
ployed the  various  suggestions  should  be  made  as 
positive  as  possible  without,  however,  allowing 
the  patient  to  become  aware  of  its  use.  The 
necessity  for  this  lies  in  the  fact  that  the  more 
apparent   and  more   direct  the  suggestion   the 


The  Special  Senses  111 

more  inclined  is  a  hypnotized  patient  to  accept 
and  to  act  upon  it,  while  in  the  application  of 
suggestion  to  one  who  is  not  hypnotized,  the 
chances  of  successful  realization  vary  directly 
with  the  patient's  ignorance  of  its  employment. 

The  effect  of  suggestive  treatment  is  mate- 
rially increased  when  the  suggestions  are  rein- 
forced and  disguised  by  the  use  of  such  an  im- 
pressive agent  as  electricity.  The  physician 
suggests,  for  instance,  that  the  blindness  will 
disappear  when  the  electrode  is  applied.  Or 
the  patient  may  be  placed  in  a  dark  room,  and, 
after  having  received  an  electrical  treatment, 
her  eyes  are  bandaged  while  she  is  assured 
that  her  sight  will  be  normal  when  the 
bandages  are  removed  the  next  morning. 

As  each  therapeutic  failure  tends  to  convince 
the  patient  of  the  incurable  nature  of  her  mal- 
ady it  is  best  not  to  incur  this  risk  and  to  waste 
valuable  time  by  holding  hypnotism  in  reserve. 
Instead  of  waiting  until  other  measures  have 
failed  we  should  use  first,  as  J.  Arthur  Booth 
has  recommended,  the  therapeutic  resource 
which  offers  the  greatest  possible  chance  of 
success;  and  this  is  hypnotic  suggestion — the 
most  effective  kind  of  suggestion.  (Hysterical 
Amblyopia  and  Amaurosis — Report  of  Five 
Cases  Treated  wdth  Hypnotism,  Med.  Rec,  Aug.. 
24,  1895.) 

Byschromatopsia.  In  the  same  manner 
that    complete    amaurosis    occurs    so    also    does 


112  Psychopathology  of  Hysteria 

psychic  blindness  for  colors — achromatopsia. 
To  the  achromatopic  patient  all  colors  appear 
grey.  The  oft  quoted  experiments  of  Parinaud 
show  that  hysteric  achromatopsia  is  entirely  a 
psychic  disturbance.  In  case  of  monocular 
color  blindness  a  green  object  appears  to  be 
grey  when  seen  by  the  achromatopic  eye.  Now, 
if  diplopia  is  produced  by  placing  a  prism  be- 
fore the  normal  eye  the  patient  may  declare 
that  both  images  are  green,  as  they  really  are. 
But,  the  production  of  diplopia  necessitates 
vision  with  both  eyes.  Therefore,  perception  of 
one  of  the  images  is  dependent  upon  an  eye 
which  is  color  blind.  If  the  patient  states  that 
both  images  are  grey  then  the  use  of  the  prism 
has  effected  a  temporary  achromatopsia  of  the 
normal  eye.  When  the  prism  is  placed  before 
the  achromatopic  eye  the  patient  declares  either 
that  both  images  are  grey  or  that  they  are 
green.  Naturally,  these  results  imply  the  same 
peculiarities  of  perception  as  did  the  results 
obtained  when  the  prism  was  placed  before  the 
normal  eye. 

Bernheim  was  the  first  to  show  that  achroma- 
topsia could  be  caused  by  means  of  hypnotic 
suggestion,  and  that  when  thus  produced  the 
condition  experimentally  is  identical  with  that 
of  hysteria.  Discarding,  therefore,  the  involved 
explanation  of  Parinaud  he  contended  that  both 
hysteric  and  hypnotic  achromatopsia  were  the 
product  of  suggestion.  In  this  he  is  sustained 
by  the  modern  French  neurologists. 


The  Special  Senses  113 

When  there  is  total  lack  of  synthesis  with  con- 
sciousness of  perceptions  of  only  one  kind  of 
color  impressions  the  cause  of  the  defect  should 
be  readily  discovered.  A  hysteric  who  has  had 
some  terrifying  or  disagreeable  experience  may 
afterwards  develop  achromatopsia  for  one  color 
which  was  prominently  identified  with  the  pain- 
ful experience.  This  partial  achromatopsia  con- 
stitutes part  of  a  reaction  of  defense  for  the 
reason  that  the  memory  complex  concerning  the 
experience  has  been  dissociated  from  conscious- 
ness and  as  conscious  perception  of  the  color 
would  subsequently  tend,  by  association  of  ideas, 
to  recall  the  dissociated  complex  these  percep- 
tions are  also  repressed. 

In  these  cases,  too,  the  disturbance  can  be 
demonstrated  to  be  psychic  in  nature.  The  neat 
experiments  of  Charcot  and  Regnard  suffice. 
These  depend  upon  the  principles  of  fusion  of 
colors.  Wlien  red  and  green  are  fused  by  me- 
chanical means — rotating  disc — the  patient  mth 
monocular  blindness  for  green  declares  that  she 
sees  a  greyish  tint.  Now,  such  a  tint,  under  these 
circumstances,  requires  the  perception  of  its 
green  constituent;  otherwise,  the  patient,  per- 
cei^dng  green  as  white,  should  see  light  red  as 
the  result  of  fusion  of  red  and  green. 

The  different  kinds  of  psychic  disturbance  of 
color  perception  are  very  infrequent  in  this 
countrj^.  May  not  the  reason  for  this  depend 
upon  the  fact  that  physicians  of  this  country  do 


114  Psychopathology  of  Hysteria 

not  usually  include  in  their  examinations  tests 
of  color  perception?  Therefore,  dyschroma- 
topsias  not  being  sought  they  are  less  apt  to  be 
accidently  suggested  upon  the  patient. 

Concentric  Contraction  of  the  Visual 
Fields.  This  '^ symptom,"  one  of  the  classic 
*' stigmata"  of  hysteria,  was  considered  to  pos- 
sess considerable  diagnostic  importance.  It  is 
probable,  however,  that  it  is  always  caused 
by  suggestion  during  perimetric  examinations 
and,  consequently,  it  is  indicative  only  of 
the  abnormal  suggestibility  which  is  essential  to 
hysteria  but  which  also  occurs  in  other  psycho- 
neuroses.  In  reference  to  86  cases  reported  from 
Bernheim's  clinic  Amselle  states  that  not  even 
once  were  hemianesthesia  and  retraction  of  the 
visual  fields  discovered  in  patients  who  had  not 
been  examined  previously.  (Conception  de 
I'Hysterie,  p.  237,  1907.) 

That  concentric  contraction  of  the  visual  fields 
is  not  a  spontaneous  symptom  of  hysteria  can 
be  reasonably  ascribed  to  the  improbability  that 
a  layman  could  conceive  such  a  condition.  As 
the  symptoms  of  hysteria  are  dependent  either 
upon  the  conceptions  of  the  patient  or  upon 
accidental  suggestion — using  this  term  in  its 
most  comprehensive  sense — one  might  lay  down 
the  axiom  that  the  hysteric  is  incapable  of  pre- 
senting any  symptom  of  which  previously  she 
did  not  have  some  conception,  or  which  was  not 
suggested  upon  her.    Neither  can  one  experience 


The  Special  Semises  115 

a  dream  whose  content  is  independent  of  all 
previous  knowledge,  nor  can  one  cause  a  hyp- 
notic subject  to  hallucinate  an  object  which  he 
had  never  perceived. 

It  is  not  intended  to  convey  the  impression 
that  concentric  contraction  of  the  visual  fields 
is  always  created  by  reason  of  a  faulty  technique 
of  examination,  but  that  the  examination  per  se 
is  sufficiently  suggestive  to  determine  the  pro- 
duction of  this  condition  unless  the  physician 
employs  suggestion  in  order  to  counteract  the 
tendency.  Except  those  patients  whose  fields 
previously  have  been  examined,  it  is  most  un- 
usual to  find  contraction  of  the  fields  in  hyst-erics 
who  are  examined  with  the  rough  finger  test, 
provided  that  this  is  performed  in  a  manner 
that  is  not  too  elaborate  nor  too  prolonged. 
"With  the  perimeter,  an  imposing  and  suggestive 
apparatus  and  one  which  requires  that  the 
patient  be  subjected  to  an  unduly  prolonged 
examination,  it  is  rare,  indeed,  not  to  find  mod- 
erate or  high  grade  contraction  of  the  fields 
unless  the  physician,  by  his  antagonistic  sug- 
gestions, prevents  the  production  of  the  condi- 
tion. 

During  former  investigations  of  the  visual 
fields  it  was  my  custom  to  eliminate  verbal  sug- 
tion,  at  least,  by  explaining  to  the  patient  just 
what  was  required;  stress  being  laid  upon  the 
injunction  that  she  was  to  say  "now"  just  as  soon 
as  she  saw  the  peripheral  white  spot.    Then  the 


116  Psychopathology  of  Hysteria 

examination  was  commenced  and  finished  with- 
out further  directions  or  remarks.  In  this  man- 
ner suggestions,  whether  tending  to  cause  or  to 
prevent  the  production  of  concentric  contrac- 
tion, are  avoided  and  only  the  suggestive  char- 
acter of  the  examination  itself  remains.  Under 
such  conditions  reduction  of  the  visual  fields 
varying  from  a  moderate  amount  to  contractions 
so  extreme  as  to  indicate  pin-point  vision  were 
invariably  found;  even  though  previous  rough 
finger  tests  showed,  in  almost  every  case,  that 
the  fields  were  approximately  normal. 

On  the  other  hand,  if  the  physician  desires  to 
avoid  the  production  of  concentric  contraction 
it  is  easy  to  do  so  by  means  of  suggestion  and 
persuasion  during  the  course  of  the  examina- 
tion. By  this  means  distraction  of  the  patient's 
attention  is  avoided,  she  is  induced  to  attend 
strictly  to  peripheral  vision,  and,  in  addition,  if 
vision  at  any  one  radius  does  not  correspond  to 
the  normal  she  is  assured  that  she  can  do  better 
than  that  and  the  test  is  repeated.  "When  this 
technique  is  adopted  concentric  contraction  of 
the  visual  fields  rarely  will  be  found  in  cases 
whose  fields  are  being  examined  for  the  first 
time. 

In  order  to  prove  that  hysteric  contraction  of 
the  fields  was  only  subjective  it  was  my  custom 
to  hold  up  several  fingers  in  the  arc  of  the  peri- 
meter well  beyond  the  limit  of  the  field  which 
had  been  previously  determined.     Upon  asking 


The  Special  Senses  117 

the  patient  if  she  saw  the  fingers  the  reply 
would  be  negative.  Then,  resorting  to  hypnosis, 
it  was  usually  easy  to  induce  her  to  state  just 
how  many  fingers  she  had  seen  in  the  supposedly 
blind  portion  of  her  field.  I  soon  found,  how- 
ever, that  hypnosis  was  unnecessary;  for  it  was 
much  easier  simply  to  ask  her  in  a  positive  man- 
ner how  many  fingers  she  saw.  Since  adopting 
this  procedure  not  one  of  perhaps  25  consecu- 
tive cases  of  hysteria  has  failed  to  ansvv^er  cor- 
rectly the  majority  or  all  of  the  times  that  the 
test  was  repeated. 

Such  a  test,  which  is  but  one  of  many  similar 
ones  which  may  be  employed,  experimentally 
proves  at  once  that  hysteric  concentric  contrac- 
tion of  the  visual  fields  is  only  a  psychic  dis- 
turbance. Clinically,  this  fact  has  been  known 
for  many  years.  How,  otherwise,  could  we  ex- 
plain the  following  case  described  by  Janet:  A 
boy  who  developed  crises  whenever  he  saw  a 
flame,  possessed  visual  fields  which  were  con- 
tracted to  5°,  yet  a  crisis  could  be  precipitated 
by  holding  a  lighted  match  at  80°  while  the 
patient  was  at  the  perimeter  and  fixing  its  cen- 
tral point.  (Major  Symptoms  of  Hysteria,  p. 
197.)  How,  too,  could  we  account  for  the  fact 
that  there  is  not  any  embarrassment  of  the 
actions  of  those  patients  whose  fields  are  con- 
tracted to  a  point,  and  in  whom  the  condition 
has  been  fixed  by  repeated  examinations  and 
clinical    demonstrations.      In   reference   to   this 


118  Psychopathology  of  Hysteria 

anomaly  Janet  writes  of  a  patient  who  was  able 
to  play  at  ball  in  spite  of  an  extreme  degree  of 
contraction  of  the  fields.  It  vv^ould  be  hardly 
necessary  to  state  that  this  would  be  absolutely 
impossible  in  case  of  organic  contraction  to  the 
same  degree.  Try  to  imagine  anyone  playing 
ball  while  looking  through  a  pair  of  telescopes 
or  a  double  barrelled  gun! 

In  spite  of  the  laws  of  optics  a  contracted  field 
of  hysteric  origin  remains  the  same  regardless 
of  any  increase  of  the  distance  at  which  it  is 
taken ;  instead  of  enlarging,  as  it  should.  Natu- 
rally, this  inconsistency  depends  upon  the  con- 
ception of  the  visual  defect  that  the  patient 
formed  during  the  first  perimetric  examination. 
Being  ignorant  of  optics  she  believes  that  the 
area  which  she  can  see  should  remain  the  same 
whether  she  is  fixing  upon  an  object  one  foot 
away,  or  on  one  which  is  at  a  distance  of  20 
feet.  It  was  remarked,  also,  that  the  size  of  the 
field  could  be  made  to  vary  according  to  the 
use  of  suggestion  by  the  examiner,  and  accord- 
ing to  the  mental  state  of  the  patient  while 
being  examined.  By  causing  the  patient  to  con- 
centrate her  attention  upon  some  problem  Janet 
secured  variations  amounting  to  as  much  as  60°. 
Finally,  it  is  possible,  with  hypnotic  suggestion 
in  almost  all  cases  and  with  suggestion  during 
the  usual  state  of  consciousness  of  the  patient  in 
most  cases,  to  enlarge,  perhaps  even  to  the 
normal,  a  contracted  field.     Likewise,  one  may 


The  Special  Senses  119 

create  a  contraction  in  patients  whose  fields 
previously  had  been  normal. 

From  a  diagnostic  point  of  view  there  should 
not  be  the  slightest  difficulty  in  differentiating 
the  concentric  contraction  of  hysteria  from  the 
infrequently  encountered  similar  visual  defect 
of  multiple  sclerosis,  or  the  quite  common  one 
of  tabes  dorsalis — 50%  of  25  cases  in  which  the 
disease  had  existed  for  an  average  of  51/2  years 
— and  of  other  varieties  of  optic  atrophy. 

The  advisability  of  producing  contraction  in 
hysteric  patients  is  decidedly  questionable; 
though  apparently  they  do  not  seem  to  incon- 
venience or  to  harm  the  patient  in  any  way, 
considered  as  a  means  of  diagnosis  the  field 
changes  that  have  been  described  can  be  re- 
garded only  as  indicative  of  abnormal  sug- 
gestibility and  not  as  essential  symptoms  of 
the  disease.  Furthermore,  the  functional  con- 
traction which  is  elicited  by  examination  is  by 
no  means  pathognomonic  of  hysteria ;  in  the 
other  psychoneuroses  it  can  be  observed  just 
as  frequently,  but  usually  not  to  such  an  ex- 
treme degree  as  we  find  in  some  cases  of 
hysteria. 

Ordinarily,  it  is  thought  that  spiral  fields  are 
characteristic  of  neurasthenia,  and  that  the 
condition  is  due  to  progressive  fatigue  occa- 
sioned by  the  examination.  In  hysteria,  never- 
theless, spiral  fields  are  created  more  commonly 
than  in  neurasthenia  when  the  perimetric  ex- 


120  Psychopathology  of  Hysteria 

animation  is  conducted  according  to  the  tech- 
nique which  I  have  described.  Moreover,  fields 
which  are  concentrically  contracted  may  be 
changed  into  spiral  fields  solely  as  the  effect 
of  the  manner  in  which  the  patient  is  ques- 
tioned during  repetition  of  the  examination. 
Let  me  adduce  a  typical  example: 

As  examined  by  the  rough  finger  test,  the 
visual  fields  of  Lizzie  B.  were  approximately 
normal;  perimetric  examination,  however,  re- 
sulted in  production  of  spiral  fields  of  small 
amplitude.  Being  so  marked,  the  contraction 
could  not  have  escaped  detection  by  the  finger 
test;  consequently,  it  must  have  been  caused 
by  the  perimeter.  During  the  same  visit,  re- 
examination resulted  in  diminution  of  the  fields 
to  a  point.  Seven  days  later  the  fields  were 
found  to  have  remained  unchanged.  After 
about  six  months  had  passed,  she  was  subjected 
to  a  third  perimetric  examination.  Commenc- 
ing at  0°  and  progressing  rapidly  from  the 
nasal  to  the  temporal  fields,  the  tests  were  made 
30°  apart  in  order  not  unduly  to  prolong  the 
examination.  After  one  complete  circuit  of  the 
left  eye  she  was  allowed  to  rest  five  minutes, 
and  then  the  right  field  was  taken.  Although 
hysteria  is  characterized  by  the  opposite  of 
abnormal  readiness  to  the  induction  of  fatigue, 
periods  of  rest  were  allowed  on  returning  to 
the  left  eye,  at  the  termination  of  each  complete 
circuit.    Proceeding  in  this  manner,  the  spiral 


The  Special  Semises  121 

field  which  was  produced  could  not  have  been 
due  to  transient  fatigue.  Being  able,  after- 
wards, correctly  to  count  fingers  which  were 
held  in  the  arc  of  the  perimeter  at  the  periphery 
of  what  should  be  the  normal  field,  she  was 
given  a  brief  explanation  of  the  fields  of  vision, 
and,  furthermore,  the  inconsistency  of  the  re- 
sults in  her  case  was  demonstrated  to  her.  Now^ 
upon  repeating  the  examination,  her  fields  were 
found  to  be  practically  normal.  Repeated 
single  tests  which  were  without  defijiite  radial 
sequence  verified  the  boundaries  of  these  fields. 
When  produced  by  the  technique  already  de- 
scribed both  spiral  fields  and  the  fact  that,  in 
case  of  concentric  contraction,  the  field  of  the 
second  eye  examined  is  usually  smaller  than 
that  of  the  first,  can  be  explained  acceptably  by 
assuming  that  the  further  one  proceeds  with  the 
examination  the  better  able  is  the  patient  to  grasp 
the  suggestion  which  it  implies,  and.  conse- 
quently, the  more  forcible  it  becomes.  This 
cumulative  effect  of  the  suggestive  nature  of 
perimetric  examination  is  like  the  cumulative 
effect  of  suggestions  during  the  hypnotic  state. 
When  a  hypnotized  subject  refuses  at  first  to 
accept  a  suggestion  often  it  is  necessary  only 
that  it  should  be  repeated  several  times,  and 
with  each  repetition  one  can  plainly  see  that  the 
resistance  of  the  subject  is  decreased  until,  fin- 
ally,  the  suggestion  is  accepted  and  acted  upon. 


122  Psych  opathology  of  Hysteria 

The  Color  Fields.  As  investigations  of 
the  color  fields  require  extended  perimetric  ex- 
amination, and  as  it  is  extremely  difficult  to 
induce  a  hysteric  to  concentrate  her  attention 
upon  one  subject  for  any  length  of  time,  such 
investigations  necessarily  must  be  extremely 
variable  in  their  results;  even  more  so  than  we 
fiend  in  our  examinations  of  the  fields  for  white. 

It  is  well  known  that  the  size  of  the  visual 
fields  of  a  hysteric  to  a  great  degree  is  de- 
pendent upon  suggestion  and  upon  the  amount 
of  concentration  of  the  patient's  attention  on 
the  examination;  distraction  of  her  attention 
being  accompanied  by  reduction  in  the  size  of 
the  field  which  is  being  examined  at  the  time. 
"Whenever  the  patient  becomes  preoccupied  with 
some  extraneous  idea,  or  whenever  her  atten- 
tion is  distracted  by  some  noise,  someone  enter- 
ing the  room,  or  what  not,  we  notice  correspond- 
ing modifications  in  the  size  of  the  visual  field. 
"We  may  find,  therefore,  that  the  field  for  red 
is  larger  than  that  for  blue  simply  because  the 
patient's  attention  was  concentrated  upon  the 
examination  while  she  was  being  tested  with  the 
first  color,  whereas  her  attention  was  distracted 
during  the  tests  with  blue.  Moreover,  being  pro- 
longed the  examination  is  apt  to  arouse  a  state 
of  indifference,  or  of  active  rebellion,  with  the 
consequence  that  each  successive  field  may  be- 
come smaller.  The  cumulative  effects  of  the 
suggestive  character  of  the  examination  tend  to 


The  Special  Senses  123 

produce  the  same  sequential  modification.  A 
priori,  then,  one  should  not  expect  to  find  any 
typical  or  constant  relative  disturbance  of  the 
color  fields.  Clinically,  this  inference  receives 
abundant  verification. 

In  their  mode  of  production  contractions  in 
the  color  fields  need  not  be  considered  as  differ- 
ing in  any  way  from  contraction  of  the  field  for 
white;  all  such  contractions  being  the  effect  of 
the  increased  suggestibility  characteristic  of 
hysteria.  It  has  been  considered  that  inversion 
of  the  color  fields  was  a  prerogative  of  hysteria. 
Of  the  greatest  importance,  therefore,  are  the 
findings  of  Bordley  and  Gushing  relative  to  the 
color  fields  in  cases  of  brain  tumor.  Their  in- 
vestigations show  that  inversion  is  just  as  char- 
acteristic of  brain  tumor  as  it  has  been  con- 
sidered to  be  of  hysteria.  (Archives  of  Ophthal., 
Sept.,  1909.)  In  a  later  paper  Gushing  and 
Heuer  (Jour,  of  the  A.  M.  A.  1911,  2,  p.  200) 
state  that  out  of  123  patients  with  brain  tumor 
in  which  perimetric  examination  could  be  made 
there  were  53  who  presented  contraction  and  in- 
version of  the  color  fields,  and,  what  is  more 
important,  in  ten  of  these  the  disturbances 
occurred  in  the  absence  of  choked  disc,  or  else 
only  a  very  incipient  process  was  found.  On 
the  other  hand,  one  must  not  forget  the  fre- 
quency with  which  symptoms  of  hysteria,  as 
Gowers  has  remarked,  are  painted  upon  a  back- 
ground of  organic  disease,  and  thus  to  ascribe 


124  Psychopathology  of  Hysteria 

to  brain  tumor  symptoms  which  may  have  been 
the  effect  of  increased  suggestibility  due  to  super- 
imposed hysteria. 

Hemianopsia.  That  hemianopsia  ever  occurs 
as  a  symptom  of  hysteria  has  been  the  subject 
of  controversy.  At  all  events,  a  few  cases  have 
been  reported,  and  besides,  there  is  no  good 
reason  for  assuming  that  this  type  of  de- 
fect in  the  visual  field  cannot  develop.  The 
infrequent  occurrence  of  hysteric  hemianopsia 
can  be  explained  on  the  grounds  that  laymen 
do  not  possess  knowledge  of  the  difference  in  the 
cerebral  distribution  of  fibres  from  different 
parts  of  the  retina,  and,  therefore,  they  cannot 
have  any  conception  of  hemianopsia.  Moreover, 
perimetric  examination,  as  usually  conducted, 
tends  to  cause  general  reduction  of  the  fields 
and  can  hardly  convey  to  the  patient  the  sug- 
gestion of  hemianopsia. 

In  about  50%  of  those  afflicted  with  migraine 
the  attack  is  preceded  by  some  visual  disturb- 
ance. Quite  commonly  this  assumes  the  form  of 
a  scintillating  scotoma  which  may  produce  com- 
plete but  transient  hemianopsia.  Now,  is  it  not 
reasonable  to  assume  that  a  hysteric  who  in  this 
manner  has  acquired  knowledge  of  homonymous 
hemianopsia  subsequently  may  develop  hysteric 
hemianopsia  ?  May  not  the  symptom  of  migraine 
or  of  auto-intoxication  become  fixed  as  a  result 
of  the  tendency  of  hysteria  to  appropriate  and 
to  elaborate  the  symptoms  of  other  diseases  ?    At 


The  Special  Senses  125 

any  rate,  one  patient  stated  that  shortly  before 
psychic  homonymous  hemianopsia  appeared  she 
had  experienced  for  the  first  time  a  scintillating 
scotoma  which  had  obscured  the  same  half  of 
her  visual  field.  If  hysteria  were  more  com- 
monly associated  with  true  migraine  probably 
hysteric  hemianopsia  would  be  less  infrequent. 

A  second  patient  declared  that  she  had  been 
ivell  until  her  fifteenth  year  when  suddenly  she 
lost  the  ability  to  see  anything  to  one  side  of 
"the  point  at  which  she  was  looking.  Without 
being  prompted  she  explained  in  detail  the  na- 
ture of  this  difficulty.  Careful  inquiry  failed 
to  disclose  the  cause  of  the  symptom;  she  had 
never  experienced  a  scintillating  scotoma,  and, 
before  the  onset  of  the  symptom,  her  eyes  had 
not  been  examined.  Following  the  first  attack 
of  hemianopsia  she  had  been  subject,  for  a 
v7hole  yeSiT,  to  other  ones  that  lasted  about 
twenty  minutes  and  which  occurred  several 
times  daily.  Beginning  with  this  visual  dis- 
turbance a  most  severe  type  of  major  hysteria 
became  evolved. 

Deafness.  In  hysteria,  whatever  is  done 
or  perceived  in  a  more  or  less  unconscious  or 
automatic  manner  is  apt  to  be  accomplished  or 
perceived  better  than  when  the  act  receives  the 
conscious  attention  of  the  patient.  On  account 
of  this,  together,  perhaps,  with  the  effects  of 
the  suggestion  implied  by  the  test,  hysteric  pa- 
tients who  present  evidences  of  possessing  an 


126  Psychopathology  of  Hysteria 

ordinary  amount  of  strength  almost  invariably 
are  incapable  of  registering  on  the  dynamome- 
ter a  degree  of  strength  greater  than  that  of  a 
child.  Or,  when  testing  vision,  conscious  per- 
ception of  the  test  letters  may  be  no  better 
than  10/50,  yet,  at  other  times,  visual  acuity  of 
the  same  patient  is  obviously  normal.  In  the 
same  manner  hysteric  patients  whose  hearing 
evidently  is  normal  almost  always  show,  when 
tested,  decided  reduction  of  acuity  of  audition ; 
unless  this  functional  impairment  is  prevented 
by  suggestion. 

Suppose  we  subject  a  number  of  hysterics  to 
an  examination  in  which  the  following  tech- 
nique be  employed:  The  patients  are  directed 
to  declare  when  they  hear  the  watch,  and  then 
no  other  remarks  are  made  during  the  course  of 
the  test.  Each  ear  is  tested  by  gradually  bring- 
ing a  watch  from  an  inaudible  distance  towards 
the  ear.  It  will  be  found  that  with  a  watch 
that  should  be  heard  at  about  three  feet,  in  the 
neighborhood  of  90%  of  the  patients  do  not 
detect  the  ticking  at  a  distance  greater  than 
about  five  inches,  and  approximately  10%  re- 
quire the  watch  to  be  placed  in  contact  with 
the  ear. 

Having  examined  a  hysteric  who  asserts  that 
she  is  unable  to  hear  the  watch  until  it  is 
placed  in  contact  with  her  ear,  and  having  had 
her  close  her  eyes,  let  us  hold  the  watch  sta- 
tionary at  almost  the  extreme  limit  at  which 


The  Special  Senses  127 

it  should  be  heard.  Now,  by  asking  at  fre- 
quent intervals,  ' '  Do  you  hear  it  yet  ? ' ',  the  im- 
pression is  conveyed  that  the  watch  is  being 
gradually  brought  closer  to  her  ear,  as  it  was 
during  the  first  test.  After  a  few  such  ques- 
tions the  patient  announces  that  she  perceives 
the  ticking.  In  the  absence  of  an  organic 
cause  for  the  impairment  this  experiment  in  my 
hands  has  failed  to  succeed  in  only  two  in- 
stances. In  a  few  cases,  however,  before  a 
positive  response  can  be  obtained  it  may  be 
necessary  to  bring  some  metallic  object  into 
contact  with  the  patient's  ear,  thus  causing  her 
to  believe  that  it  is  the  watch  which  she  feels. 
Having  demonstrated  the  subjective  nature  of 
the  reduction  in  hearing,  and  while  retaining 
the  watch  in  the  same  position,  the  patient  is 
told  to  open  her  eyes.  Being  aware  of  the 
deficiency  brought  about  by  the  first  test,  she 
at  once  expresses  surprise  at  the  distance  at 
which  she  heard  the  watch,  and,  what  is  impor- 
tant, she  continues  to  hear  it  at  the  same  dis- 
tance. 

In  testing  v^th  the  Galton  whistle  often  we 
find  that  the  highest  notes  are  not  consciously 
perceived  by  the  patient,  but  this  has  the  same 
significance  as  the  defects  brought  about  by 
testing  acuity  of  audition,  or  of  vision.  Occa- 
sionally, it  is  possible  to  demonstrate  very 
nicely  with  the  Galton  whistle  the  pathogenic 
effects  of  a  suggestive  technique  of  examina- 


128  Fsyclwpathology  of  Hysteria 

tion.  The  patient  is  told  to  apprise  us  when  she 
begins  to  hear  the  whistle,  and  then,  progres- 
sively lowering  the  pitch  from  the  extreme 
limit  of  normal  audibility,  we  find  that  she  fails 
to  hear  the  whistle  until  a  note  of,  for  instance, 
21,000  vibrations  is  obtained.  Now,  suppose 
we  instruct  her  to  notify  us  when  she  is  not 
able  any  longer  to  hear  the  whistle.  Continu- 
ing gradually  to  lower  the  pitch,  infrequently 
we  may  find  that  she  is  unable  to  hear  a  note 
whose  vibrations  are  less,  for  example,  than 
10,500.  No  other  interpretation  can  be  placed 
upon  such  curious  results  than  that  they  were 
determined  entirely  by  suggestion. 

In  addition  to  these  rudimentary  and  practi- 
cally inocuous  kinds  of  temporary  disturbance 
of  auditory  perception,  complete  unilateral  or 
bilateral  psychic  deafness  is  uncommonly  en- 
countered. When  unilateral,  psychic  deafness, 
like  hysteric  monocular  amaurosis,  may  occur  in 
association  with  hemianesthesia  and  other  dis- 
turbances of  perception  of  sensory  impressions 
arising  from  the  same  side  of  the  body;  the 
association  of  these  symptoms  being  due  solely 
to  the  patient's  belief  that  hemianaesthesia 
must  necessarily  include  homolateral  loss  of  all 
forms  of  sensibility. 

"When  occurring  independently  of  hemi- 
anaesthesia, unilateral  psychic  deafness  is  often 
evolved  from  some  unimportant  local  affection 
which  concentrates  the  patient 's  attention  upon 


The  Special  Senses  129 

her  ear,  and  upon  hearing,  or  it  may  be  the 
consequence  of  the  psychic  effects  of  trauma- 
tism to  the  ear. 

The  history  of  one  patient  showed  that  the 
condition  had  developed  from  what  presum- 
ably was  a  furuncle  of  the  external  auditory 
canal.  Two  years  after  the  onset,  a  compe- 
tent otologist,  finding  that  the  auditory  ap- 
paratus was  normal,  advised  her  to  consult  a 
neurologist.  When  engaged  in  conversation, 
the  patient  did  not  appear  to  be  inconvenienced 
except  when  her  attention  was  directed  to  her 
hearing.  Then,  turning  her  sound  ear  towards 
the  person  with  whom  she  was  conversing,  she 
seemed  to  experience  difficulty  in  perceiving 
what  was  said,  and  occasionally  she  required 
that  a  sentence  be  repeated.  When  tested  with 
the  fork,  she  asserted  that  she  was  unable  to 
hear  either  by  osseous  or  aerial  conduction. 
With  the  exception  of  the  psychoneuroses  such 
a  finding  indicates  organic  nerve  deafness.  But, 
when  the  auditory  apparatus  of  only  one  side 
is  the  seat  of  organic  nerve  deafness,  osseous 
conduction  is  not  entirely  lost  because  the 
vibrations  are  transmitted  across. the  skull  to 
the  opposite  side. 

When  examining  patients  with  psychic  deaf- 
ness, the  results  of  tests  necessarily  must  be  in 
accordance  with  the  patient's  conception  of 
deafness.  Consequently,  all  kinds  of  auditory 
impressions,  whether  these  be  the  product  of 


130  Psychopathology  of  Hysteria 

aerial  or  of  osseous  conduction,  fail  to  be  syn- 
tlietized  with  consciousness — they  lack  personal 
perception.  If  a  hypnotized  subject  accepts  the 
suggestion  that  he  cannot  hear  with  one  ear, 
one  will  find  that  the  same  results  are  obtained 
with  the  fork.  In  addition  to  those  patients 
who  present  loss  of  both  forms  of  sensibility 
occasionally  we  find  one  in  whom  the  tests  show 
apparent  loss  of  osseous  conduction  with  pres- 
ervation of  aerial  conduction.  This  finding  can 
occur  only  as,  a  result  of  suggestion  in  psycho- 
neurotic patients. 

Reverting  to  our  patient,  after  inducing  the 
hypnotic  state,  it  was  easy  to  effect  partial 
return  of  bone  conduction.  After  a  few  subse- 
quent treatments,  air  conduction  at  first  was 
secured,  and  then  caused  progressively  to  im- 
prove until  it  became  normal.  During  the  fol- 
lowing eighteen  months  that  she  was  under 
observation  not  any  further  auditory  difficulty 
was  experienced. 

The  occasional  association  of  deafness  and 
mutism  is  probably  due  to  the  popular  knowl- 
edge of  the  frequency  with  which  mutism 
occurs  as  a  complication  of  organic  deafness. 
In  the  case  of  Mabel  A.,  total  psychic  deafness, 
associated  with  mutism,  suddenly  developed 
without  any  ascertainable  cause.  After  lasting 
four  days,  speech  and  hearing  returned,  but 
for  over  a  month,  attacks  of  deaf -mutism  re- 
curred every  afternoon  at  the  same  hour  that 


The  Special  Senses  131 

the  first  attack  had  appeared.  Save  the  initial 
alarm  at  the  sudden  appearance  of  these  major 
symptoms,  she  was  not  disturbed  in  any  way, 
and,  in  fact,  she  was  reluctant  to  consult 
a  physician.  During  the  first  attack,  aerial  and 
bone  conduction  were  absent,  and  she  seemed 
totally  unable  to  speak  or  to  hear.  In  this 
case,  too,  the  symptoms  were  readily  infiuenced 
by  hypnotic  suggestion — adopted  on  the  nine- 
teenth day — and,  after  two  treatments,  the  at- 
tacks no  longer  recurred. 

The  psychic  nature  of  hysteric  disturbances 
of  sensory  perception  are  well  illustrated  by 
Oettinger's  interesting  case.  After  a  period  of 
auto-hypnotic  sleep,  this  patient  exhibited  deaf- 
mutism  which  persisted  for  over  four  months. 
In  explanation  of  his  comprehension  of  what 
was  said  to  him,  he  asserted,  in  writing,  that 
he  could  read  the  lips  of  those  who  talked  to 
him,  yet  it  was  found  that  he  was  unable  to 
read  the  lips  during  silent  speech.  Further- 
more, when  the  babies  cried  in  the  children's 
ward  he  volunteered  his  services,  though  he  could 
obtain  knowledge  of  the  opportunity  for  his 
assistance  only  by  hearing  the  crying.  Several 
other  inconsistencies  were  also  apparent.  The 
symptoms  disappeared  spontaneously  in  this 
case;  faradism  having  been  ineffectual  and 
efforts  to  hypnotize  him  having  proved  fruitless. 
Afterwards,  he  spoke  complacently  of  his  suc- 
cessful resistance  to  suggestion.  (Jour,  of  Nerv. 
and  Ment.  Dis.,  1908,  p.  129.) 


132  Psychopathclogy  of  Hysteria 

The  character  of  the  disturbance  has  been 
ludicrous  in  some  of  the  recorded  cases  of  hys- 
teric deafness.  Knapp's  case,  for  example,  was 
treated  for  a  couple  of  Aveeks  with  suggestive 
applications  of  faradism  with  the  result  that  her 
complete  deafness  was  changed  to  word  deaf- 
ness. The  peculiarity  consisted  in  her  ability 
to  hear  her  own  voice,  though  unable  to  hear 
the  voices  of  others.  Further  improvement  hav- 
ing taken  place,  she  became  able  to  hear  the 
voices  of  females,  but  psychic  deafness  for  male 
voices  continued  to  exist.  (]\Ionatsschr.  f. 
Psychiat.  u.  Neur.,  Dec,  1907.) 

The  distinction  between  organic  deafness  and 
that  due  to  hysteria  should  not  be  difficult. 
Sometimes  one  can  startle  the  patient  into  dis- 
closing her  consciousness  of  a  noise.  This  pro- 
cedure, however,  not  only  is  crude  but  it  should 
succeed  only  in  cases  of  malingering,  or  of  hys- 
teric malingering.  A  better  method  is  to  at- 
tempt to  produce,  by  suggestion,  subconscious 
reaction  to  auditory  stimuli.  One  may  succeed 
in  demonstrating  that  a  case  of  deafness  is  not 
organic  by  means  of  another  device  which  is 
dependent  upon  suggestion.  In  the  presence 
of  the  patient  the  physician,  after  having  deter- 
mined that  what  he  is  about  to  suggest  is  not 
already  present,  incidentally  remarks  to  who- 
ever happens  to  be  present  that  the  patient 
should  present  such  and  such  a  sign.  If  the 
case  is  one  of  hysteria,  subsequent  examination 


The  Special  Senses  133 

may  show  that,  in  the  interval,  the  patient  has 
developed  the  sign  which  she  has  been  induced 
to  believe  is  essential  to  her  disease.  Finally, 
with  suggestion  it  may  be  possible  at  once  par- 
tially or  eompleteh^  to  restore  normal  hearing. 

Smell  and  Taste.  Psychic  anosmia  and  psy- 
chic ageusia  are  encountered  less  frequent- 
ly than  similar  disturbances  of  vision  and  of 
audition  because  the  senses  of  smell  and  of 
taste  are  rarely  examined  by  physicians,  and, 
therefore,  these  conditions  are  not  so  liable  to 
be  produced  as  artefacts.  Probably  the  major- 
ity of  cases  of  unilateral  anosmia  and  ageusia 
are  only  part  of  hemianiesthesia,  and  the  asso- 
ciation of  the  symptoms  is  the  consequence  of 
the  patient's  conception  of  hemiangesthesia.  By 
reason  of  his  faulty  technique  of  examination 
some  physician  creates  hemiansesthesia.  and 
then  he.  or  some  other  one.  discovers  by  fur- 
ther tests  that  the  patient  has  homolateral 
deafness,  amaurosis,  anosmia,  and  ageusia. 

Wlien  cases  of  anosmia  and  ageusia  are  sub- 
jected to  critical  examination  the  results,  from 
a  physiologic  standpoint,  are  remarkable.  Mary 
D.,  for  example,  never  had  been  aware  of  any 
disturbance  of  sensory  perception  until  a  phy- 
sician had  "discovered"  hemiauEesthesia  and 
hemianalgesia.  Months  afterwards  she  was 
unable,  during  my  tests  at  least,  consciously  to 
perceive  tactile,  thermal,  painful,  or  pressure 
stimuli  applied  to  the  right  side.       The  other 


134  Psychopathology  of  Hysteria 

physicians  who  had  examined  her  had  not 
tested  her  special  senses,  and,  as  far  as  she  was 
aware,  these  had  not  been  impaired.  My  ex- 
amination, conducted  in  the  usual  manner,  i.  e., 
without  attempting  to  avoid  the  production  of 
symptoms,  showed  unilateral  deficiency  of  all 
the  special  senses  of  the  right  side.  Therefore, 
either  these  troubles  had  existed  unbeknownst 
to  her,  or  my  examination  was  their  sole  cause. 
At  an}^  rate,  though  olfaction  by  means  of  the 
left  nostril  was  not  impaired  she  asserted  that 
she  was  unable  to  perceive  any  odor  when  she 
smelled  various  test  substances  while  the  left 
nostril  was  occluded.  Except  as  a  manifesta- 
tion of  hysteria  this  condition  would  be  most 
remarkable,  indeed,  for  even  if  the  odors  were 
received  only  through  the  nostril  of  the  affected 
side  unilateral  anosmia  could  not  cause  total 
abolition  of  the  sense  of  smell.  Not  only  would 
the  posterior  naris  of  the  sound  side  aid  in 
detection  of  the  odor,  but,  with  some  odors,  the 
associated  sense  of  taste  alone  would  be  suffi- 
cient. 

From  a  physiological  point  of  view  even 
more  extraordinary  is  the  fact  that  inhalation 
of  ammonia  through  the  right  nostril  was 
absolutely  devoid  of  reaction.  As  a  conse- 
quence, then,  of  her  firm  conviction  that  she 
was  unable  to  smell  with  her  right  nostril,  there 
results  associated  immunity  from  the  usual 
effects  of  ammonia  upon  respiration.     This  in- 


The  Special  Senses  135 

stance  of  the  total  inhibition  of  the  effects  of 
such  a  powerful  respiratory  stimulant  is  a  re- 
markable, but  not  unique,  example  of  the  exalt- 
ed power,  in  hysteria,  of  the  mind  over  the 
body. 

In  the  same  patient  the  substances  usually 
employed  for  testing  the  gustatory  sense  were 
readily  perceived  when  applied  to  the  left  side 
of  the  tongue.  On  the  other  side,  however,  they 
were  not  detected  until  the  tongue  was  with- 
drawn, and  then  only  with  difficulty,  or  not 
at  all.  In  addition  to  unilateral  anosmia  and 
unilateral  ageusia,  this  patient  had  almost  com- 
plete monocular  amaurosis — ^V.  0.  D.  4/200 — 
miilateral  deafness,  and  incomplete  hemiplegia. 


CHAPTER   V 

Visceral  and  Circulatory  Derangements 

RESPIRATORY  System.  Except  com- 
plete cessation  of  breathing  hysteria 
can  occasion  all  the  possible  vari- 
ations of  respiration.  The  atten- 
tion of  the  patient  may  have  been  concen- 
trated upon  the  respiratory  effects  of  great 
excitement  with  the  consequence  that  these' 
normal  reactions  have  become  fixed  as  symp- 
toms of  hysteria.  Or,  the  respiratory  symp- 
toms resulting  from  accidental  and  transient 
organic  disease  may  be  prolonged  in  the  same 
manner.  There  is  a  tendency  for  a  hysteric  to 
develop  the  symptoms  with  which  she  is  most 
familiar,  so  that  long  after  having  become 
acquainted  with  the  symptoms  which  resulted 
from  some  organic  disease,  or  from  excitement, 
these  may  return  as  hysteric  manifestations, 
consequent  upon  some  psychic  trauma  which 
she  has  undergone.  In  this  case  the  relation 
between  the  exciting  cause  and  its  effect  is  dif- 
ficult to  understand  unless  the  former  incident 
is  known. 

Naturally  the  frequency  of  respiration  be- 
comes increased  during  convulsive  and  emo- 
tional attacks,  but  sometimes  the  symptom  oc- 
curs independently,  and  it  may  persist  for 
weeks.      Often   it  is   paroxysmal;   recurrences 

136 


Visceral  and  Circulatory  Derangements  137 

being  effected  by  mental  stresses.  The  rate 
may  be  increased  to  an  extent  which  can  be 
scarcely  credited.  In  a  case  recorded  by  Char- 
cot respiration  attained  a  frequency  of  180  per 
minute.  During  hysteric  ''coma"  brought 
about  by  a  mental  shock  one  patient  who  came 
under  my  observation  exhibited  a  respiratory 
rate  of  120  for  several  hours,  over  100  for  more 
than  a  day,  and  between  80  and  108  for  several 
days.  A  few  days  later  a  second  attack  de- 
veloped, and  during  five  consecutive  days  respi- 
ration was  maintained  between  50  and  80.  It 
is  remarkable,  indeed,  that  such  a  rate  could 
have  been  maintained  for  this  length  of  time. 
One  has  only  to  attempt  voluntarily  to  breathe 
this  rapidly  in  order  at  once  to  discover  how 
difficult  and  how  exhausting  it  is. 

Spasmodic  disturbances  of  respiration  are 
usuall}^  due  to  true  volitional  tics  of  the  respi- 
ratory muscles,  and  they  occur  in  patients  who 
do  not  present  any  of  the  signs  of  hysteria,  but 
rather  those  of  psychasthenia.  These  tics,  like 
similar  ones  in  other  parts  of  the  body,  are 
produced  by  obsessions  which  the  patient  is 
impelled  to  gratify,  and  thej^  are  accompanied 
by  self-consciousness  and  shame.  Generally 
speaking,  spasmodic  disturbances  of  breathing 
are  not  due  to  psychasthenia  when  they  cannot 
be  voluntarily  duplicated.  For  instance,  one 
never  encounters  attacks  of  sneezing  or  of  true 
singultus     in    typical    psychasthenics.         The 


138  Psychopathology  of  Hysteria 

mechanism  of  the  spasmodic  respiratory  symp- 
toms of  hysteria  is  entirely  subconscious,  and, 
therefore,  these  manifestations  are  not  pro- 
duced by  conscious  efforts,  nor  are  they  de- 
pendent upon  conscious  impulsions.  Instead 
of  being  ashamed  the  patient  ignores  her  respi- 
ratory tics ;  she  may  be  even  unaware  of  them. 

Abnormally  frequent  sighing  and  yawning 
is  often  seen  in  cases  of  hysteria,  but  these 
symptoms  are  comparatively  unimportant. 
Several  times  a  year  the  dispensaries  of  large 
hospitals  receive  patients  who  present  contin- 
ued singultus  vera.  By  means  of  the  news- 
papers these  cases  may  be  traced  from  one  dis- 
pensary to  another  until,  after  several  days, 
weeks,  or  months,  the  symptom  disappears.  In 
spite  of  various  kinds  of  treatments  in  different 
hospitals,  hiccough  had  continued  to  occur 
about  every  thirty  seconds  in  one  of  my  cases. 
By  means  of  hypnotic  suggestion  the  symptom 
was  immediately  removed. 

Attacks  of  sneezing  and  of  rhinorrhoea  some- 
times appear  during  emotional  excitement.  In 
one  instance  I  have  known  a  young  lady  by 
psychic  contagion  alone  to  contract  such  at- 
tacks from  her  sister.  When  sufficiently  elab- 
orated these  attacks  constitute  what  cannot 
be  differentiated  from  the  syndrome  known  as 
hay  fever.  Suppose  an  acute  rhinitis  with 
sneezing  is  acquired  by  an  individual  at  a  time 
of  the  year  when  ordinary  colds  are  uncommon 


Visceral  and  Circulatory  Derangements  139 

— when  hay  fever  is  in  season.  More  than  one 
kind  friend  may  express  sympathy  while  in- 
forming the  patient  that  the  condition  is  hay 
fever,  and  that  it  will  return  at  the  same  time 
every  year.  This  suggestive  explanation  is  apt 
to  be  accepted,  especially  by  one  who  obviously 
is  hysteric,  with  the  consequence  that  the 
individual  begins  to  anticipate  his  ''hay  fever'* 
at  about  the  same  time  the  following  year.  Now, 
if  this  state  of  expectant  attention  is  sufficiently 
developed  to  produce  recurrence  of  the  symp- 
toms of  what  originally  was  an  ordinary  cold, 
then  a  precedent  is  established,  an  association 
neurosis  is  formed,  and  each  recurrence  only 
strengthens  the  primarily  weak  associations 
just  as  any  habit  becomes  more  fixed  as  the 
result  of  repeated  indulgence. 

Morton  Prince  has  reported  an  instance  of 
*'hay  fever''  existing  as  a  neurosis  in  five  mem- 
bers of  one  family.  One  of  these  patients  was 
told  by  a  physician  that  fruit  was  capable  of 
inducing  attacks.  Subsequently,  she  was 
unable  to  eat  fruit  without  suffering  from  hay 
fever.  The  evident  influence  of  autosuggestion 
in  the  production  of  hay  fever  caused  Prince 
to  propound  the  question:  *'May  not  a  very 
large  number — one  cannot  generalize  too  ex- 
tensively and  say  all — of  the  cases  of  recurrent 
periodic  hay  fever  develop  in  the  same  way? 
May  not  the  attacks  come  on  at  a  certain  date 
because    of    apprehension    or    expectancy,    by 


140  PsycJiopatJiology  of  Hysteria 

which  the  patient  suggests  to  himself  or  her- 
self that  at  that  time  he  or  she  will  be  suscep- 
tible to  external  irritants  of  one  kind  or  an- 
other, and  then  at  the  suggested  time  the  irri- 
tant produces  its  habitual  and  expected  ef- 
fect?" (Annals  of  Gynaecology  and  Paediatry, 
1895). 

How  often  we  encounter  patients  who  declare 
that  their  hay  fever  will  begin  on  a  certain 
date, — that  such  always  has  been  the  case !  Be- 
cause change  of  environment  is  reputed  to  be 
effectual  in  warding  off  recurrences  of  hay  fever, 
and  because  they  know  from  experience  that  such 
often  has  been  the  case,  these  patients,  if  their 
position  in  life  enables  them  to  do  so,  will  com- 
mence long  in  advance  of  the  set  date  to  arrange 
their  affairs  so  that  they  can  escape  to  their 
favorite  retreat  just  before  the  attack  is  due.  In 
a  case  of  hysteria  such  a  state  of  mind  certainly 
is  most  favorable  for  the  induction  of  what  is 
expected  so  confidently;  either  the  appearance 
of  an  attack  about  the  time  it  is  expected,  or 
the  avoidance  of  one  resulting  from  the  pa- 
tient's conviction  relative  to  the  prophylactic 
effects  of  a  prospective  vacation.  Concerning 
the  yearly  recurrence  of  attacks  on  a  fixed  date. 
Prince  questions  the  pathogenic  influence,  other 
than  through  the  agency  of  expectancy,  of  the 
relative  position  of  the  moon  to  the  earth. 

That  many,  at  least,  of  the  cases  of  what 
clinically  is  kno^^^l  as  hay  fever  are  really  symp- 


Visceral  and  Circulatory  Derangements  141 

toms  of  hysteria  is  sho\\Ti  by  the  fact  that  we 
xiSLB.  cure  many  of  these  cases  by  no  other  means 
than  suggestion.  On  the  other  hand,  Prince 
has  been  able  to  produce  coryza  by  means  of  de- 
liberate post  hypnotic  suggestion.  Having  sug- 
gested during  hypnosis  to  ''B.  C.  A."  that  the 
presence  of  a  certain  flower  caused  hay  fever 
subsequently  she  developed  coryza  when  exposed 
to  this  flower,  even  though  she  had  never  had 
liay  fever,  or  thought  about  it,  before  the  sug- 
gestion had  been  made.  After  having  been 
awakened  she  did  not  remember  the  suggestion, 
^nd  when  the  coryza  appeared  the  thought 
flashed  into  her  mind  that  if  it  were  summer  she 
would  think  she  had  hay  fever.  ( The  Mechanism 
of  Recurrent  Psychopathic  States,  with  Special 
Reference  to  Anxiety  States,  Jour,  of  Abnormal 
Psychology,  Yol.  6,  p.  148.) 

It  seems  that  hysteria  is  capable  of  causing 
what  cannot  be  differentiated  from  asthma,  as 
far  as  symptoms  and  clinical  signs  are  concerned. 
As  a  matter  of  fact,  many  cases  of  psychogenic 
asthma  have  been  reported,  and  the  cure  of  such 
<;ases  through  the  agency  of  hypnotic  suggestion 
is  ample  proof  of  the  validity  of  the  diagnosis. 

For  nine  years,  Mr.  X.,  an  indi^ddual  whose 
manifestations  were  those  of  hysteria  and  who 
also  presented  psychasthenic  fears,  had  been 
afflicted  with  frecjuently  recurring  attacks  which 
were  typical  of  asthma.  The  seizures  first  ap- 
peared during  an  attack  of  influenza,  and  they 


142  Psychopathology  of  Hysteria 

recurred  every  morning  at  about  three  o'clock. 
Examination  of  his  chest  revealed  the  typical 
signs  that  one  would  expect  to  find  in  a  case  of 
asthma  of  nine  years  duration.  Since  the  first 
treatment  with  hypnotic  suggestion  the  patient 
has  not  had  a  single  attack  of  asthma.  (Report 
of  a  Case  of  Dissociated  Personality,  Jour,  of 
Abnormal  Psychology,  Aug.-Sept.,  1909.) 

Before  the  true  nature  of  the  condition  was 
recognized  another  patient  had  been  treated  in 
a  hospital  a  whole  week  for  cardiac  asthma. 
The  attacks  occurred  several  times  daily  and 
each  lasted  about  a  half  hour.  One  appeared 
during  his  visit  to  the  dispensary.  Following 
a  sudden  deep  inspiration,  rapid  stertorous 
respiration  developed,  the  face  became  cyan- 
otic, and  lachrjnuation  occurred.  After  about 
a  half  minute  the  neck  became  extended  and 
rigid,  the  hands  tightly  clenched,  the  limbs 
catatonic,  and  the  pupils  widely  dilated.  This 
phase  of  the  seizure  lasted  about  two  minutes, 
and  then  he  relaxed,  and  dyspnoea  continued  in 
association  with  a  succession  of  brief  attacks 
whose  main  features  were  general  but  moderate 
clonic  movements  and  a  state  of  consciousness 
resembling  the  somnambulistic  states  of  hys- 
teria or  of  hypnosis.  That  the  attacks  were 
due  to  hysteria  was  indubitable.  As  the  pa- 
tient did  not  return — he  lived  at  some  distance 
from  the  city — the  outcome  of  the  treatment 
is  not  known. 


Visceral  and  Circulatory  Derangements  143 

A  third  patient,  aet.  23,  had  suffered  from 
asthma  since  an  attack  of  pertussis  in  his 
eighth  year.  Severe  asthmatic  seizures  which 
lasted  over  48  hours  occurred  about  once 
monthly.  These  were  so  severe  that  he  was 
totally  incapacitated  for  three  or  four  days, 
and,  on  account  of  losing  so  much  time  from 
his  work,  he  was  about  to  be  discharged  from 
his  place  of  employment.  Each  of  the  major 
attacks  was  preceded  for  24  hours  by  decided 
aggravation  of  his  bronchial  symptoms.  In  no 
way  did  his  seizures  differ  from  what  is  typical 
asthma,  and  not  any  of  the  physicians  who  had 
examined  him  had  questioned  the  diagnosis. 
In  addition  to  the  severe  attacks,  he  was  sub- 
ject to  lesser  ones  which  occurred  twice  every 
night  and  which  lasted  about  three-quarters  of 
an  hour.  These  mild  ones  were  prone  to  arouse 
him  at  two  and  at  five-thirty  in  the  morning. 
The  physical  signs  were  those  characteristic  of 
well  developed  asthma ;  namely,  the  physical 
signs  of  chronic  bronchitis  and  emphysema. 

The  treatment  consisted  entirely  of  hypnotic 
suggestion.  The  first  treatment  was  given 
while  the  patient  was  having  one  of  his  severe 
attacks.  Immediately  upon  the  induction  of 
hypnosis  his  respiration  became  decidedly  less 
difficult.  During  the  following  24  hours  his 
symptoms,  though  very  distressing,  were  much 
less  severe  than  usual.  Extending  over  a 
period  of  four  months  he  was  hypnotized  seven 


144  Psychopathology  of  Hysteria 

times  with  the  following  results:  After  the 
first  treatment  he  did  not  have  a  single  severe 
attack,  and  the  milder  ones  progressively  im- 
proved until  they,  too,  entirely  disappeared 
after  the  sixth  treatment. 

Alimentary  System.  The  experiments  of 
Pawlow,  Cannon,  and  others  have  shown  the 
great  importance  of  the  effects  of  appetite  and 
of  emotions  upon  the  secretion  of  gastric  juice. 
The  experiments  of  Pawlow,  (The  Work  of  the 
Digestive  Glands,  1910,)  for  instance,  showed 
that  the  mere  exhibition  of  food  to  a  dog  re- 
sulted in  the  secretion  of  gastric  juice  in  quan- 
tities which  actually  exceeded  those  provoked 
by  allowing  the  dog  to  swallow  the  same  food 
and  to  eject  it  through  an  oesophageal  fistula. 
It  was  observed,  also,  that  the  quantity  of 
juice  secreted  largely  depended  upon  the  in- 
tensity of  the  desire  for  food,  so  that  the  author 
says  emphatically:  "Appetite  spells  gastric 
juice.''  The  truth  of  this  dictum  was  unques- 
tionably demonstrated  by  the  fact  that  though 
the  sight  of  food  induced  almost  immediate 
and  copious  secretion  of  gastric  juice,  yet,  pro- 
viding only  that  the  animal  was  unaware  of 
the  presence  of  food,  the  direct  introduction  of 
food  through  a  gastric  fistula  was  followed  by 
the  secretion  of  a  greatly  inferior  quantity  of 
the  juice,  and  the  appearance  of  this  secretion 
was  delayed  for  one-half  to  several  hours. 


Visceral  and  Circulatory  Derangements  145 

Depressing  emotions  not  only  cause  an  un- 
pleasant dryness  of  the  mouth  but  they  are 
capable  also  of  inhibiting  gastric  secretion. 
Moreover,  the  digestive  juices  are  not  secreted 
in  sufficient  quantities  when  one  eats  without 
experiencing  desire  for  food,  or  when  there  is 
positive  distaste  for  food.  As  a  secondary  pro- 
cess fermentation  occurs,  followed  by  auto-in- 
toxication and  anorexia — a  vicious  circle  is 
formed. 

In  most  of  the  cases  of  gastric  neurosis  the 
patient,  possessing  an  elaborate  system  of 
erroneous  ideas  concerning  digestion,  believes 
that  he  has  some  organic  gastric  disease.  Con- 
stantly being  obsessed  by  the  fear  that  through 
some  dietary  indiscretion  he  will  aggravate  his 
existing  dyspepsia  the  flow  of  digestive  juices 
is  rendered  insufficient  as  a  result  of  his  de- 
pressing mental  states  during  meals.  This  type 
of  gastric  neurosis,  or  ''emotional  dyspepsia," 
may  be  classified  as  a  manifestation  of  psychas- 
thenia.  Less  frequently  the  condition  occurs 
in  hysteria.  In  this  case  the  imperfect  secre- 
tion of  the  digestive  juices  is  due  to  absence  of 
appetite — psychic  anorexia — ;  the  patient  eating 
in  order  to  avoid  the  importunities  of  the 
family.  Or,  attacks  of  indigestion  may  follow 
■undue  emotional  activity. 

The  following  instance,  mentioned  by  W.  B. 
Cannon,  well  illustrates  the  disturbing  effects 
of  emotional  excitement  upon  digestion:     "A 


146     "     Psychopathology  of  Hysteria 

refined  and  sensitive  woman  who  had  had 
digestive  difficulties,  came  with  her  husband  to 
Boston  to  be  examined.  The  next  morning  the 
woman  appeared  at  the  consultant's  office  an 
hour  after  having  eaten  a  test  meal.  An  ex- 
amination of  the  gastric  contents  revealed  no 
free  acid,  no  digestion  of  the  breakfast,  and 
the  presence  of  a  considerable  amount  of  the 
supper  of  the  previous  evening.  The  explana- 
tion of  this  stasis  of  the  food  in  the  stomach 
came  from  the  family  doctor,  who  reported  that 
the  husband  had  made  the  visit  to  the  city  an 
occasion  for  becoming  uncontrollably  drunk, 
and  that  he  had  by  his  escapades  given  his  wife 
a  night  of  turbulent  anxiety.  The  second 
morning,  after  the  woman  had  had  a  good  rest, 
the  gastric  contents  were  again  examined;  the 
proper  acidity  was  found,  and  the  test  break- 
fast had  been  normally  digested  and  dis- 
charged." (Amer.  Jour,  of  the  Med.  Sci.  Apr. 
1909.) 

Anorexia.  The  most  grave  of  the  symp- 
toms of  hysteria  is  anorexia;  a  condition  which 
only  too  frequently  has  eventuated  in  death. 
Since  the  introduction  of  rectal  alimentation  and 
the  stomach  tube  death  from  hysteric  anorexia 
would  seem  to  be  unpardonable.  The  anorexia 
has  been  ascribed  to  visceral  anaesthesia,  but  it 
should  be  remembered  that  this  anaesthesia,  like 
the  other  varieties,  must  be  only  subjective ;  the 
condition  being  the  result  of  lack  of  synthesis 


Visceral  and  Cirmdatory  Derangements  147 

wdth  consciousness  of  the  perceptions  of  coenes- 
thetic  impressions  pertaining  to  the  feeling  of 
hunger  —  the  feeling  of  need  for  food.  The 
stomach  is  not  the  only  factor  concerned  in  the 
feeling  of  hunger,  and,  therefore,  a  hypothetical 
gastric  anaesthesia  does  not  explain  hysteric 
anorexia.  If  an  ecstatic  is  firmly  convinced  that 
she  can  live  without  eating,  if  she  believes  that 
she  is  the  instrument  of  a  miracle,  complete  dis- 
sociation can  occur  of  all  the  perceptions  con- 
cerned in  the  composition  of  the  feeling  of  hun- 
ger, just  as  Miss  Beauchamp  developed  systema- 
tized lack  of  perception  of  auditory,  tactile,  and 
visual  impressions  arising  from  the  rings  which 
she  thought  she  had  lost. 

The  origin  of  this  peculiar  and  dangerous 
symptom  may  have  been  some  former  event 
which  was  prominently  associated  with  eating, 
or  the  idea  of  hunger,  and  which  made  a  strong 
impression  upon  the  patient's  mind.  Or  it  may 
have  been  the  result  of  hysteric  elaboration  and 
fixation  of  a  purely  symptomatic  and  transient 
distaste  for  food.  In  some  cases  the  symptom 
is  the  direct  outcome  of  too  careful  dieting,  by 
physicians,  of  patients  mth  hysteric  disturbances 
of  digestion;  the  patient  gradually  eliminating 
from  her  diet  one  kind  of  food  after  another, 
as  the  feeling  of  the  need  for  food  gradually  is 
dissociated.  Regardless  of  the  cause,  the  patient 
refuses  to  eat  because  there  is  an  absolute  lack 
of  desire  for  food,  even  though  there  is  not  any 


148  Psychopathology  of  Hysteria 

real  disturbance  of  the  digestive  system,  and  in 
spite  of  the  fact  that  emaciation  progresses 
rapidly.  Janet  describes  a  case  whose  anorexia 
was  dependent  upon  hallucinatory  commands 
from  her  dead  mother,  who,  reproaching  her 
for  some  faults  she  had  committed,  told  her  that 
she  was  not  worthy  to  live,  and  that  by  refusing 
to  eat  she  should  rejoin  her  in  heaven.  (Mental 
State  of  Hystericals,  p.  288.) 

In  addition  to  true  psychic  anorexia  hysteric 
individuals  may  simulate  the  condition  in  order 
to  attract  attention  to  themselves  and  to  excite 
wonder.  In  such  cases  the  patient  affirms  that 
she  can  live  without  eating,  or  that  she  cannot 
eat  because  she  has  no  desire  for  food;  yet 
emaciation  does  not  ensue  because  privately 
she  is  consuming  a  sufficient  amount  of  food. 
Notwithstanding  the  fact  that  the  condition  is 
simulated  the  patient  cannot  be  called  a 
malingerer  with  any  greater  justice  than  one 
can  apply  the  same  designation  to  an  insane 
patient  who  simulates  certain  of  his  manifesta- 
tions in  consequence  of  motives  which,  them- 
selves, are  symptoms  of  insanity. 

As  these  cases  of  simulated  anorexia  or  fast- 
ing usually  occur  in  hysterics,  the  patient,  if 
prevented  from  secretly  obtaining  nourishment, 
may  starve  herself  to  death  rather  than  ac- 
knowledge the  deception  which  she  has  prac- 
ticed. Hammond  made  a  collection  of  cases  of 
simulated  fasting,  and  in  one  instance — Sarah 


Visceral  and  Circulatory  Derangements  149 

Jacob— to  the  disgrace  of  all  those  concerned, 
including  a  vicar,  nurses,  and  physicians,  the 
patient  was  forced  to  starve  herself  to  death 
because  the   careful   guarding   by  nurses  that 
had  been  sent  from  Guy's  Hospital  finally  pre- 
vented any  further  eating  in  private.     In  the 
interest  of  science  and  truth,  then,  a  hysteric 
girl  was  forced  to  commit  suicide.    Those  who 
were  responsible  for  the  fatal  outcome  escaped 
serious     consequences,     except     the     patient's 
father  and  mother,  who  were  committed  to  jail 
for    12    and   6   months   respectively.   (Nervous 
Derangement  1883,  p.  95.) 

The  anorexias  of  hysteria  should  not  be  con- 
founded with  those  of  psychasthenia.  The 
psychasthenic  refuses  to  eat  not  because  he 
lacks  desire  for  food,  but  principally  through 
fear  of  the  gastric  distress,  or  other  suffering, 
that  he  knows  will  surely  follow.  This 
emotional  dyspepsia  of  expectancy  and  fear 
constitutes  the  very  common  gastric  neurosis 
in  whose  production  the  physician  is  the  main 
factor  by  reason  of  his  paying  too  much  atten- 
tion to  the  organs  of  digestion  instead  of  to  the 
patient. 

Vomiting.  Hysteric  vomiting,  another  serious 
manifestation  which  has  been  known  to  ter- 
minate in  death,  and  which  usually  occurs 
in  association  with  hysteric  anorexia,  is  not  at 
all  uncommon.  Generally  its  origin  is  found  to 
be  some  former  acute  disease  which  occasioned 


150  Fsychopathology  of  Hysteria 

vomiting,  and,  after  the  original  cause  sub- 
sided, the  symptom  continued  as  a  manifes- 
tation of  hysteria.  By  reason,  too,  of  ex- 
pectant attention,  or  what  really  is  unconscious 
autosuggestion,  the  physiological  vomiting  of 
pregnancy  can  be  caused  to  persist. 

Just  as  the  normal  person  may  experience 
nausea,  and  even  vomiting,  as  a  concomitant  of 
disgust,  so  the  hysteric  may  suffer  from  hyper- 
emesis  as  a  result  of  subconscious  ideation.  It 
is  well  known  that  association  of  ideas  is  ca- 
pable of  producing  vomiting.  A  typical  instance 
is  mentioned  by  Carpenter:  "Thus  Van 
Swieten  relates  of  himself,  that,  having  chanced 
to  pass  a  spot  where  the  bursting  of  the  dead 
body  of  a  dog  produced  such  a  stench  as  made 
him  vomit,  on  passing  the  same  spot  some  years 
afterwards  he  was  so  vividly  affected  by  the 
recollection,  that  the  sickness  and  even  vomit- 
ing recurred."  (Mental  Physiology,  p.  432, 
1883.)  If  Van  Swieten  had  forgotten  the 
original  disgusting  experience  with  the  conse- 
quence that  each  time  he  vomited  he  had  been 
ignorant  of  its  cause,  then  his  case  would  be 
identical  with  the  mechanism  of  production  — 
subconscious  association  of  ideas  —  of  symp- 
toms of  hysteria.  As  it  was  it  resembled  psy- 
chasthenia  in  that  the  symptoms  were  the  effect 
of  conscious  association  of  ideas. 

The  hysteric,  then,  may  vomit  whenever  there 
is  aroused  into  activity,  by  association  of  ideas, 


Visceral  and  Circulatory  Berangeraents  151 

a  dissociated  complex  of  memories  of  some  for- 
mer experience  which  made  a  distinct  impres- 
sion upon  the  patient,  and  in  which  vomiting 
was  a  prominent  factor.  As  the  provocative 
association  of  ideas  usually  occurs  below  the 
level  of  consciousness,  it  is  only  by  some  psy- 
choanalytic method  that  the  origin  of  the  con- 
dition can  be  discovered.  Motor  activity  of  this 
sort,  whether  it  is  a  convulsion,  a  contracture, 
a  tremor,  vomiting  or  what  not,  constitutes 
what  is  termed  motor  automotism;  a  condition 
characterized  by  motor  activity  independently 
of  consciousness;  a  dissociation  of  motor  ac- 
tivity. 

In  treating  a  case  of  alcoholism  with  hypnotic 
suggestion  we  may  artificially  create  a  motor 
automatism  whose  psychic  mechanism  is  identi- 
cal wdth  that  of  hysteria.  While  the  patient  is 
in  the  hypnotic  state  suggestions  are  made  that 
tend  to  strengthen  his  moral  character;  which 
are  directed  against  the  fundamental  neurosis; 
ones  which  are  calculated  to  abolish  the  crav- 
ing. Then  we  may  suggest  that  the  idea  of  drink- 
ing liquor  ^dll  always  be  associated  ^vith  a  feel- 
ing of  disgust,  that  the  odor  alone  will  nauseate 
him.  and  that  if  he  should  ever  take  any  alco- 
holic drink  he  would  vomit  immediately.  If 
the  patient  is  a  good  hypnotic  subject  he  will 
not  remember  any  of  these  suggestions  after 
the  hypnotic  state  is  dispelled.  In  this  manner 
we  have  produced  a  dissociated  memory  com- 


152  Psychopathology  of  Hysteria 

plex  which,  when  aroused  into  activity  by  the 
proper  stimuhis,  should  produce  vomiting. 
Now,  if  at  any  time  the  patient  should  take 
some  whiskey  he  would  probably  vomit,  and, 
like  the  hysteric,  he  would  not  know  the  real 
cause  of  his  vomiting — the  association  of  ideas 
would  be  subconscious. 

Often  the  vomitus  contains  blood,  and  then 
the  diagnosis  becomes  difficult  indeed.  If  we 
accept  the  possibility  of  vasomotor  disturb- 
ances due  to  the  disease,  then  true  hysteric 
hsematemesis  can  occur  just  as  other  hsemor- 
rhagic  conditions  have  been  known  to  be  pro- 
duced both  by  hysteria  and  by  hypnotic  sug- 
gestion. Excepting  this  possibility,  one  which 
is  the  subject  of  much  controversy  and  which 
must  be  extremely  infrequent,  all  cases  of 
hysteric  hsematemesis  are  merely  instances  of 
deception:  as  far  at  least,  as  the  presence  of 
blood  in  the  vomitus  is  concerned.  At  all 
events,  in  each  of  the  few  cases  which  have 
come  under  my  observation  the  patient  had 
swallowed  blood  procured  by  picking  at  the 
nostrils  until  epistaxis  was  produced. 

Even  though  a  patient  with  hysteric  vomit- 
ing deliberately  simulates  hasmatemesis  such 
deception  cannot  be  regarded  other  than  as  a 
manifestation  of  a  pathologic  mental  state. 
With  no  other  object  than  to  gain  sympathy 
certainly  no  normal  persons  would  carry  the 
deception  so  far  as  to  seek,  and  to  undergo, 


Visceral  and  Circulatory  Derangements  153 

operations  for  supposed  gastric  ulcer.  This 
type  of  deception  is  malingering  only  to  the 
same  extent  as  that  of  cases  of  hysteria  in 
which  simulated  anorexia  has  terminated  in 
death.  Surely,  malingering  for  the  purpose  of 
exciting  sympathy,  or  wonder,  is  as  much  a 
symptom  of  hysteria  as  a  psychic  hemiplegia 
or  a  psychic  amaurosis. 

The  differential  diagnosis  in  cases  of  hysteria 
presenting  haematemesis  is  extremely  difficult. 
Only  those  who  have  had  cause  to  worry  much 
about  cases  of  hysteria  whose  symptoms  in- 
cluded anorexia,  vomiting,  localized  epigastric 
pain,  tenderness,  and  perhaps  hgematemesis, 
can  appreciate  just  how  difficult  the  diagnostic 
problem  may  become.  Even  if  haematemesis 
appears  in  a  patient  who  is  known  to  be  a 
major  hysteric,  one  may  not  jump  at  conclu- 
sions and  dismiss  the  question  of  gastric  ulcer 
with  the  inference  that  the  condition  is  ''only 
hysterical."  In  some  cases  the  physician  must 
treat  the  patient  as  though  the  symptoms  were 
due  to  gastric  ulcer,  notwithstanding  that  he 
may  surmise  them  to  be  but  manifestations  of 
hysteria  and  knowing  that  if  this  be  the  case 
his  treatment,  even  if  successful  as  far  as  the 
present  symptoms  are  concerned,  is  almost  sure 
to  aggravate  the  fundamental  psychopathic 
state. 

A  problem  that  infrequently  may  confront 
the  surgeon  is  due  to  hysteric  reproduction  of 


154  Psychopathology  of  Hysteria 

the  symptoms  of  bowel  obstruction.  In  addi- 
tion to  obstinate  constipation,  abdominal  dis- 
tention, pain  and  vomiting,  the  patient  may- 
develop  faecal  vomiting.  In  some  cases  rectal 
injections  of  various  fluids,  including  castor 
oil,  have  been  followed  in  from  12  to  15  min- 
utes by  expulsion  of  the  injected  substance 
from  the  mouth. 

Aerophagia.  Swallowing  of  air  frequently 
occurs  as  a  symptom  of  hysteria.  As  a  con- 
sequence of  the  distress  which  is  occasioned 
the  patient  voluntarily  belches  at  frequent  in- 
tervals. Ordinarily  an  eructation  occurs  more 
or  less  spontaneously;  otherwise  it  must  be 
initiated  by  gulping  of  air.  The  aerophagic  is 
the  victim  of  a  vicious  circle:  she  belches  in 
order  to  relieve  her  gastric  distress,  and  with 
each  eructation  she  swallows  more  air. 

In  case  the  ingested  air  is  forced  through  the 
pylorus  meteorism  develops.  The  old  theory 
that  attributed  meteorism  to  paresis  of  the  in- 
testinal muscles  with  consequent  expansion  of 
the  gaseous  contents  of  the  bowels,  is  not  in  ac- 
cordance with  the  fact  that  usually  the  condi- 
tion disappears  when  the  patient  is  anaesthetized. 
Instead  of  causing  meteorism  to  vanish  the  mus- 
cular relaxation  which  is  induced  by  ether  or 
chloroform  anaesthesia  should  permit  further 
abdominal  distention  were  the  condition  due  to 
intestinal  paresis. 

When   abdominal   distention   is   produced   by 


Visceral  and  Circulatory  Derangements  155 

spasm  of  the  diai)hragm  the  distention  cannot 
be  as  great  as  that  due  to  gerophagia.  It  is  this 
spastic  type  which  disappears  during  general 
anaesthesia,  and,  as  shown  by  Janet,  during 
laughter,  sobbing,  and  hiccoughing — phenomena 
which  are  dependent  upon  normal  activity  of  the 
diaphragm.  By  means  of  radiographic  examina- 
tions Bernheim  found  that  the  diaphragm  is  low- 
ered daring  meteorism,  and  that  as  the  abdomi- 
nal distention  is  diminished  through  the  agency 
of  suggestion  the  diaphragm  gradually  ascends 
and  coimnences  to  take  part  in  the  function 
of  respiration.  (Hypnotisme  &  Suggestion, 
1910,  p.  380.) 

Meteorism  may  lead  to  enormous  distention  of 
the  abdomen.  The  enlargement  may  be  gradual 
and  associated  ^dth  symptoms  of  pregnancy,  so 
that  in  not  a  few  cases  of  pseudocyesis  physicians 
have  been  deceived  until  labor  should  have  com- 
menced. The  production  of  simple  amenorrhoea 
by  expectancy  and  fear  is  quite  common,  and 
this  effect  of  vaso  motor  disturbance  is  much 
more  remarkable  than  any  of  the  other  symp- 
toms which  enter  into  the  make  up  of  pseudocye- 
sis. The  symptoms  are  due  to  the  patient's  con- 
viction that  pregnancy  exists,  and,  needless  to 
say,  this  belief  may  be  born  either  of  great  de- 
sire for  a  child,  or  of  intense  fear  of  becoming 
pregnant.  Preston  mentions  the  ludicrous 
ease  of  a  girl  who  believed  herself  to  be  preg- 
nant as  a  result  of  masturbation  and  whose  abdo- 


156  PsychopatJwlogy  of  Hysteria 

men  was  moderately  distended.  (Hysteria  and 
Allied  Conditions,  1897,  p.  181.) 

Wesley  Taylor  describes  a  case  of  hysteric 
aerophagia  in  which  the  abdomen  was  distended 
to  a  degree  greater  than  that  of  pregnancy  at 
the  ninth  month.  The  meteorism  of  this  patient, 
a  girl  of  twenty  years,  occurred  paroxysmally, 
and  during  the  height  of  one  of  the  attacks,  the 
condition  somewhat  resembled  general  periton- 
itis. The  attacks  appeared  as  often  as  every 
two  weeks  and  lasted  as  long  as  ten  days  or 
more.  The  interesting  feature  of  the  case  was 
the  fact  that  once  she  had  been  subjected  to 
an  operation  and,  on  another  occasion,  she  es- 
caped a  second  one  only  because  of  the  rapid 
disappearance  of  the  distention  during  etheriza- 
tion.    (Jour.-Record  of  Med.,  1909,  p.  74.) 

In  addition  to  general  gaseous  distention  of 
the  abdomen  localized  tumor  like  masses  have 
been  known  to  occur  in  hysteria.  These  phan- 
tom tumors,  whether  due  to  localized  collections 
of  gas  in  the  intestines  or  to  isolated  muscular 
contraction  in  the  abdominal  wall,  have  been 
mistaken  for  real  tumors,  and  even  operations 
have  been  performed  to  the  chagrin  of  the  sur- 
geon. 

The  appetite  of  the  hysteric  is  capricious. 
In  addition  to  craving  unusual  articles  of  diet 
she  may  ingest  such  substances  as  plaster  and 
hair.  Including  his  own  case,  Butterworth 
collected  from  the  literature  42  cases  of  hair 


Visceral  and  Circulatory  Derangements  157 

ball  of  the  stomach.  Of  these  patients  39  were 
females.  The  largest  hair  cast  weighed  about 
six  pounds.  The  final  results  of  33  eases  com- 
prised 17  laparotomies  with  one  death,  6  deaths 
from  peritonitis  and  perforation,  and  10  deaths 
from  inanition.  Thus  the  outcome  was  fatal  in 
over  half  of  the  cases  in  which  this  was  known. 
The  correct  diagnosis  was  made  before  opera- 
tion in  only  five  instances.  (Jour,  of  the  A.  M. 
A.,  1909,  2,  617.) 

It  is  difficult  to  conceive  the  possibility  of 
the  production  by  hysteria  of  symptoms  capable 
of  being  mistaken  for  acute  appendicitis,  yet 
such  is  not  rare.  Twenty  cases  of  hysteric 
pseudo-appendicitis  were  compiled  by  Karl 
Urband.  A  patient  of  his  own  developed 
acutely  localized  pain  and  rigidity,  associated 
with  slight  abdominal  distention,  vomiting, 
superficial  respiration,  temperature  99%  and 
pulse  72.  Subsequently  these  symptoms  sub- 
sided, but  several  weeks  later,  following  a  chill, 
the  temperature  rose  to  104%  and  the  pulse  to 
144  only  to  fall  again 'to  normal  the  next  day. 
After  twelve  more  days  he  had  another  chill 
and  similar  rise  in  temperature  in  addition  to 
severe  pain  in  the  region  of  the  appendix.  At 
operation  the  appendix  was  found  to  be  nor- 
mal.    (Wiener  Med.  Woch.,  1908.  p.  1918.) 

EverjT-  one  of  the  usual  symptoms  of  acute 
appendicitis,  including  moderate  rise  of  tem- 
perature, was  reproduced  by  a  major  hysteric 


158  PsychopatJiology  of  Hysteria 

who  came  under  my  own  observation.  The 
elimination  of  appendicitis  was  accomplished 
only  by  the  discovery  of  two  significant  fea- 
tures: during  the  painful  reaction  produced 
by  deep  pressure  over  McBumey's  point  the 
patient's  respiration  became  deeper  than  usual, 
and  when  the  pressure  was  exerted  while  the 
patient's  attention  was  distracted  both  the 
rigidity  and  the  painful  reaction  were  found 
to  be  absent. 

Prolonged  attacks  of  diarrhoea  or  of  obsti- 
nate constipation  are  common.  More  impor- 
tant is  the  occurrence  of  what  is  called  mucus, 
or  membranous,  entero-colitis.  Whether  this 
condition  be  looked  upon  as  a  symptom  of 
hysteria  or  as  an  independent  clinical  entity, 
the  fact  remains  that  it  is  said  to  occur  only 
in  psychoneurotic  persons.  The  affection  is 
characterized  by  attacks  of  severe  abdominal 
pain  that  may  last  several  days  or  longer  and 
which  are  associated  with,  or  are  followed  by, 
the  presence  in  the  stools  of  considerable  mucus 
and  even  blood ;  the  patient  perhaps  being  free 
from  abdominal  symptoms  in  the  intervals  be- 
tween attacks.  When  the  mucus  is  passed  in 
the  form  of  tubular  casts  that  present  the 
appearance  of  membranes,  the  condition  is 
called  membranous  entero-colitis.  Either  of 
these  abdominal  crises  may  recur  for  many 
years,  apparently  without  being  influenced  by 
treatment. 


Visceral  and  Circulatory  Derangements  159 

A  patient  who  presented  an  admixture  of 
symptoms  of  hysteria  and  of  psychasthenia  for 
years  had  been  subject  to  severe  attacks  which 
usually  followed  undue  excitement,  and  which 
occurred  several  times  a  month.  During  the 
crises  her  stools  were  extremely  offensive  and 
consisted  lars:ely  of  mucus  mixed,  at  times, 
with  blood.  Rarely  casts  were  passed.  While 
she  was  travelling  in  Germany  some  intra- 
abdominal operation  was  performed  during  one 
of  the  attacks,  but  subsequently  recurrences 
took  place  as  before.  Much  to  my  surprise  the 
attacks  ceased  to  appear  shortly  after  the  adop- 
tion of  treatment  with  hypnotic  suggestion 
which  was  directed  mainly  against  the  asso- 
ciated symptoms. 

The  different  abdominal  syndromes  resulting 
from  hysteria  are  most  resistent  to  treatment, 
and  each  may  appear,  continue  indefinitely,  and 
then  disappear  suddenly  without  apparently 
having  been  influenced  at  all  by  any  of  the 
therapeutic  measures  that  had  been  adopted. 

Genito-Urinary  Derangements.  Increased 
frequency  of  urination  often  occurs  in  hysteria, 
but  more  commonly  this  symptom  is  caused 
by  a  psychasthenic  fear  that  the  necessity  to 
urinate  will  appear  at  a  time  when  social  con- 
siderations would  render  the  act  impossible; 
the  patient  urinates,  therefore,  at  frequent 
intervals  in  order  to  avoid  such  embarass- 
ment,   and,   when  the  fear  is   well   developed, 


160  Psychopathology  of  Hysteria 

he  may  refrain  even  from  going  to  places 
of  amusement  or  to  social  events.  In  such 
cases  the  fear  results  from  conscious  associa- 
tion of  ideas  with  the  memory  complex  of 
some  former  experience  when  distress  was 
caused  by  actual  necessity  to  urinate  at  a  time 
when  the  circumstances  were  such  that  the  act 
was  impossible.  In  hysteria,  on  the  other 
hand,  the  urinary  frequency  is  not  associated 
with  fear,  and  the  underlying  association  of 
ideas  is  not  consciously  known.  Further  to 
differentiate  the  two  conditions  one  might  say 
that  the  psychasthenic  urinates  too  frequently 
in  order  that  he  may  be  in  a  position  the  longer 
to  hold  his  urine  should  this  be  required,  while 
the  hysteric  variety  is  due  to  unconscious  auto- 
suggestion, and  the  act  of  micturition  occurs 
regardless  of  thoughts  of  future  environment. 
In  psychasthenia  the  condition  is  the  result  of 
an  obsession;  in  hysteria  it  is  due  to  what  is 
termed  a  sensory  automatism.  As  a  conse- 
quence of  subconscious  ideation  the  hysteric  is 
subject  to  hallucinations  of  imperative  sensory 
impressions  from  the  bladder. 

Polyuria  occurs  frequently  at  the  termina- 
tion of  hysteric  seizures,  and,  less  often,  an 
increased  amount  of  urine  may  be  passed  daily 
for  long  periods  of  time  independently  of  crises 
and  without  discoverable  cause  other  than  hys- 
teria. 

That   complete   anuria   lasting  several   days 


Visceral  and  Circulatory  Derangements  161 

can  occur  as  a  symptom  of  hysteria  has  been 
the  subject  of  much  dispute,  but  more  than  one 
case  has  been  recorded  in  which  deception 
could  be  eliminated.  Less  infrequently  the 
daily  amount  of  urine  voided  has  been  reduced 
to  a  few  ounces,  or  less,  and  the  deficiency  has 
continued  for  days  or  weeks  at  a  time.  In 
either  case  the  absence  of  urgemia  is  explained 
by  the  fact  that  in  these  patients  anuria  is 
compensated  by  profuse  sweating,  vomiting, 
or  diarrhoea.  Frequently  patients  are  encoun- 
tered who  maintain  either  that  they  do  not  pass 
any  urine  at  all,  or  that  the  amount  has  been 
reduced  to  a  few  spoonsful,  yet,  when  kept 
under  supervision,  or  if  catheterized,  the  re- 
sults show  that  deception  is  being  practiced. 

The  majority  of  cases  of  hysteric  retention 
of  urine  are  due  to  the  continuation  produced 
by  autosuggestion,  of  the  common  but  tem- 
porary post-operative  retention.  In  such  cases 
the  longer  catheterization  is  continued  the 
longer  it  wiU  be  necessary,  so  that  strenuous 
means  should  be  adopted  to  cause  the  patient 
normally  to  urinate  soon  after  operations  have 
been  performed.  Retention  often  is  simulated, 
and,  like  anuria,  the  deception  can  be  exposed 
by  catheterization  and  close  observation. 

Quite  the  reverse  of  the  ordinary  conceptions 
of  the  sexual  instinct  in  hysteria  is  the  actual 
state  of  the  genital  function.  Taking  into  con- 
sideration the  vast  numbers  of  hysterics,  rarely, 


162  Psychopathology  of  Hysteria 

indeed,  does  the  disease  produce  inordinate 
desire  and  gratification.  Less  infrequently  the 
sexual  instinct  manifests  itself  by  symbolic 
mental  activity,  or  by  conversion  into  the  physi- 
cal manifestations  of  hysteria.  Usually  the 
patient  not  only  loses  whatever  sexual  desire 
she  may  have  possessed,  but  sexual  intercourse 
becomes  repugnant.  It  is  not  at  all  uncommon 
for  patients  to  remark  that  since  they  became 
nervous  they  have  been  sexually  indifferent, 
whereas  the  opposite  formerly  was  the  case 
with  them.  It  is  true,  however,  that  excluding 
those  cases  due  to  cultivation,  degeneration, 
and  insanity,  the  majority  of  sexual  perverts 
owe  their  perverse  inclinations  to  associations 
of  ideas  which  were  usually  originated  in  early 
life.  A  number  of  cases  have  been  subjected 
to  psycho-analysis  and  the  reports  have  been 
most  instructive,  both  in  accounting  for  con- 
ditions which  heretofore  have  been  erroneously 
grasped,  and  in  adducing  further  corroboration 
of  the  theory  of  submerged  complexes  as  the 
underlying  psychic  mechanism  of  the  psycho- 
neuroses. 

In  addition  to  other  manifestations  of  hys- 
teria and  of  psychasthenia  a  patient  who  was 
studied  by  Sidis  was  obsessed  with  ideas  of 
homosexual  relations.  Hypnoidal  psycho- 
analysis brought  out  the  fact  that  when  the 
patient  was  in  his  eighth  year  some  older 
schoolmates  had  forcibly  violated  him.    Having 


Visceral  and  Circulatory  Derangements  163 

informed  his  parents  of  the  fact  he  was  removed 
from  the  school.  ''This  experience  lapsed  from 
his  conscious  memory,  but  remained  firmly  im- 
planted on  his  subconscious  memory,  giving 
rise  to  the  apparently  unaccountable  homo- 
sexual ideas  at  which  he  felt  so  much  disgust. 
The  homo-sexual  ideas  were  really  foreign  to 
his  character  and  no  wonder  his  whole  nature 
felt  revolting  disgust  towards  them. ' '  ( Studies 
in  Psychopathology,  Boston  Med.  and  Surg. 
Jour.,  Mar.  14  to  Apr.  11,  1907.) 

According  to  the  nature   of  the  perversion 
itself,  and  according  to  the  character  of  asso- 
ciated symptoms,   the   patients   may  be   classi- 
fied   either    as    hysterics    or    as    psychasthen- 
ics.    When    the    perverse    ideation    or    actual 
gratification    is     dependent     upon     obsessions 
against  which  the  patient  strives  in  vain  the 
condition    may    be    designated    psychasthenic. 
Besides  the  instance  just  mentioned  the  Hev. 
A.  Kampmeier's  case  illustrates  the  character 
of  psychasthenic  deviations  of  the  sexual  in- 
stinct.   After  reading  a  book  which  dealt  with 
the   evil  consequences  of  sexual  irregularities 
the  patient  "became  very  chaste  from  fear  of 
the  horrible  consequences  of  a  lapse  from  vir- 
tue."    Obsessions  having  developed  from  the 
material  afforded  by  the  well-meant   but   de- 
cidedly pernicious   book,  the  patient  suffered 
much  psychic  distress  and  then,  as  he  expresses 
the  outcome:    "My  demon  finally  drove  me  to 


164  Psychopathology  of  Hysteria 

make  true  what  I  imagined  would  inevitably 
come  about  had  I  not  read  that  book.  I  gave 
myself  up  to  sexual  excesses,  not  for  the  pleas- 
ure of  them,  since  in  my  case  this  was  impos- 
ible,  but  to  make  true  what  I  thought  would 
have  been  my  fate."  (Confessions  of  a  Psych- 
asthenic, Jour,  of  Abnormal  Psych.,  vol.  2, 
p.  112.) 

As  a  slight  amount  of  distress  in  the  ovarian 
regions  may  be  considered  a  concomitant  of 
normal  menstruation  it  is  just  as  natural  for 
this  normal  symptom  to  become  elaborated  and 
fixed  by  autosuggestion  as  it  is  for  a  sympto- 
matic anaesthesia  or  paralysis  to  become  fixed 
in  a  similar  manner.  Therefore,  in  most  female 
hysterics  a  suitable  foundation  is  commonly  at 
hand  for  the  development  of  psychic  pains  in 
the  ovarian  regions.  It  is  unusual  for  a  lap- 
arotomy to  show  that  both  ovaries  are  entirely 
free  from  lesions,  negligible  or  otherwise,  and, 
following  the  removal  of  one  or  both  ovaries, 
the  pain  is  very  apt  to  disappear  as  the  result 
of  the  powerful  suggestive  effects  of  an  opera- 
tion. These  facts  account  for  the  former  dis- 
graceful popularity  of  oophorectomy.  Possible 
suggestive  effects  being  insufficient  justifica- 
tion, gynaecologic  operations  should  never  be 
performed  on  a  hysteric  unless  the  same  pro- 
cedures positively  would  be  indicated  in  the 
absence  of  hysteria. 

In  reference    to    the    relation    between    the 


Visceral  and  Circulatory  Derangements  165 

psychoneuroses  and  the  pelvic  viscera  the  re- 
sults of  Clara  T.  Dercura's  statistical  analysis 
of  591  gynaecologic  patients  are  most  interest- 
ing. "The  above  tables,"  she  concludes, 
"speak  for  themselves;  there  is  obviously  no 
relation  between  hysterical  stigmata  and  pelvic 
disease ;  this  is  likewise  true  of  the  symptoms 
of  neurasthenia.  That  hysteria  and  neuras- 
thenia can  coexist  with  pelvic  disease  goes 
without  saying,  just  as  they  may  coexist  with 
a  brain  tumor  or  a  broken  leg.  The  above 
statistics  do  not  even  show  that  neurasthenia 
or  hysteria  exist  as  frequently  in  pelvic  dis- 
eases as  in  other  visceral  affections.  Certainly 
the  above  facts  prove  that  operations  on  the 
pelvic  and  other  viscera  for  the  relief  of  ner- 
vous symptoms  have  no  justification.  It  is  per- 
fectly clear  that  no  operation  should  be  per- 
formed which  has  no  positive  surgical  indica- 
tions. When  this  subject  is  fully  understood 
the  fastening  up  of  so-called  loose  kidneys,  the 
removal  of  normal  ovaries  and  tubes,  of  normal 
uteri,  of  normal  appendices,  of  pieces  of  normal 
coccygeal  bone,  will  cease,  as  will  also  repair  of 
trivial  cervical  lacerations.  A  careful  exam- 
ination of  the  records  from  hospital  labora- 
tories will  abundantly  testify  to  this  assertion 
of  the  removal  of  normal  organs."  (Jour,  of 
the  A.  M.  A.,  March  13,  1909,  p.  848.) 

Circulatory     and     Trophic     Phenomena. 
Cardiac  neuroses  seldom  are  found  in  hysteria; 


166  Psychopathology  of  Hysteria 

these  conditions  being  part  of  the  symptom- 
atology of  psychasthenia.  Increased  frequency 
of  the  cardiac  rate  accompanies  hysteric  crises 
for  the  reason  that  it  is  a  normal  concomitant 
of  emotional  excitement  or  a  normal  consequence 
of  muscular  effort.  Less  easily  understood  are 
some  of  the  vasomotor  and  trophic  manifestations 
which  seem  rarely  to  occur  as  symptoms  of  hys- 
teria, and  whose  origin  in  this  manner  is  denied 
by  many.  Sudden  flushing  of  the  face,  coldness, 
and  even  local  asphyxia,  are  ordinary  symptoms. 
The  effect  of  the  mind  upon  the  vasomotor  func- 
tion is  apparent  in  the  anaesthesias  both  of  hys- 
teria and  of  hypnosis  in  that  it  is  difficult  some- 
times to  obtain  a  free  capillary  flow  of  blood 
from  anaesthetic  regions.  More  remarkable  are 
the  rare  instances  of  spontaneous  capillary 
haemorrhage  that  occurred  in  the  so-called  stig- 
matics.  Of  these  the  best  known  is  Louise 
Lateau;  a  typical  hysteric  in  whom  haemor- 
rhages mainly  from  the  hands,  feet,  fore- 
head and  left  side  of  the  chest  appeared  every 
Friday  during  a  state  of  ecstasy  in  which  she 
acted  the  crucifixion.  The  hemorrhages  took 
place  even  though  an  apparatus  was  applied 
for  the  purpose  of  preventing  deception.  Ac- 
cording to  Dr.  Lefebvre  about  %  of  a  quart  of 
blood  was  lost  each  time  the  haemorrhages  oc- 
curred. Physicians  who  studied  the  case  came 
to  the  conclusion  that  the  phenomena  resulted 
from  autosuggestion.      With  hypnotic  sugges- 


Visceral  and  Circulatory  Derangements  167 

tion  Bourru  and  Burot,  and  Mabille  succeeded 
in  producing  similar  manifestations. 

Hysteric  purpura  is  an  uncommon  condition. 
While  examining  a  hysteric  more  than  a  dozen 
purpuric  spots  varying  in  size  from  i/^  to  3 
inches  in  diameter  were  found  in  various  parts 
of  her  body,  yet  she  had  not  known  that  a 
physical  examination  was  to  be  made  and  she 
denied  having  been  injured  in  any  way.  Her 
blood  was  found  to  be  normal.  The  purpuric 
■areas  did  not  disappear  for  more  than  two 
weeks. 

Circumscribed  oedema  may  develop  acutely 
or  slowly,  and,  after  lasting  an  indefinite  length 
of  time,  it  may  disappear  just  as  suddenly  or 
gradually.  The  lesion  is  white  or  bluish  and 
pits  but  little  under  pressure.  When  occurring 
about  joints — especially  when  associated  with 
pain  and  paresis — the  condition  may  be  mis- 
taken for  arthritis.  What  has  been  termed 
hydrops  articulorum  intermittens  is  similar  to 
the  oedema  of  hysteria,  and  it  occurs  most  fre- 
quently in  the  functional  neuroses.  As  defined 
by  W.  Healy  it  is:  ''A  chronic  affection  char- 
acterized by  an  effusion  poured  out  into  one 
or  rarely  more  joints,  at  regular  or  irregular 
intervals,  without  any  ascertainable  exciting 
cause  for  the  recurrence,  and  without  any  per- 
ceptible anatomic  alteration  as  cause  or  result 
of  the  repeated  attacks.''  (Surg.  Gyn.,  and 
Obstet.,  1908,  p.  466.)     The  nature  of  the  con- 


168  Psychopathology  of  Hysteria 

dition  is  indicated  by  the  fact  that  psychic  in- 
fluences are  ca^jable  of  inducing  attacks,  abort- 
ing them,  and  even  in  curing  the  disease. 
The  possibility  that  some  of  the  symptoms  of 
hysteria  may  result  from  localized  areas  of 
angioneurotic  cedema  in  the  brain  has  been  sug- 
gested tentatively  by  G.  L.  Walton.  (Internat. 
Clinics,  vol.  3,  series  18,  p.  242.) 

Hysteric  gangrene  is  another  of  the  mani- 
festations which  is  subject  to  controversy;  not 
only  because  of  the  difficulty  in  explaining  its 
mechanism,  but  also  because  of  the  frequency 
with  which  the  lesions  are  the  product  of  de- 
ception. Thus,  Dieulafoy's  patient,  a  male  hys- 
teric, by  chemical  irritation  caused  multiple  re- 
curring gangrene  which  was  diagnosed  trophic 
ulceration  by  a  surgeon  who  amputated  one  of 
the  patient's  arms  because  of  the  continued  re- 
currence of  the  lesions.  (La  Presse  Medicale, 
1908,  p.  369.) 

There  are  numerous  instances  on  record  of 
the  successful  production,  by  means  of  hypnotic 
suggestion,  of  dermographia,  inflammation, 
bullae,  ulceration,  and  gangrene.  Many  of  these 
experiments  were  conducted  under  conditions 
which  precluded  the  possibility  of  deception. 
By  means  of  the  application  of  objects  with  the 
suggestion  that  they  were  hot,  it  was  possible 
with  lima  S.  to  cause  skin  lesions  varying  from 
simple  redness  to  actual  ulceration.  These 
reactions  were  obtained  even  when  the  parts 


Visceral  and  Circulatory  Derangements  169 

were  carefully  bandaged  and  sealed.  (An 
Experimental  Study  in  the  Domain  of  Hypnot- 
ism, by  Von  Krafft-Ebing,  Chaddoek  trans., 
1896.)  ' 

Beaunis  described  some  interesting  experi- 
ments which  were  performed  by  Focachon  in 
the  presence  of  Bernheim,  Liebault,  and  him- 
self. Postage  stamps  having  been  applied  to 
the  subject's  back  with  the  suggestion  that 
they  were  blisters,  bandages  were  adjusted. 
Twenty-one  hours  later  a  decided  inflammatory 
reaction  was  found  when  the  stamps  were  re- 
moved, and  these  areas  developed,  in  eight 
more  hours,  into  blisters.  After  fourteen  days 
suppuration  still  continued.  On  the  other  hand, 
by  means  of  suggestion  Focachon  prevented  any 
reaction  from  a  real  blister  which  was  applied 
to  one  arm,  while  a  second  one  placed  on  the 
opposite  arm  produced  the  usual  effect.  (Du 
Somnambulisme  Provoque,  1886.)  Certainly  if 
such  lesions  can  be  produced  with  hypnotic 
suggestion  then  there  is  no  reason  why  hysteria 
cannot  do  likewise. 

As  the  influence  of  emotional  states  upon  the 
secretions  is  well  known  the  fact  that  profuse 
localized  or  general  sweating  may  occur  in 
hysteria  is  accepted  without  dispute. 

A  remarkable  instance  has  been  reported  by 
Curschmann.  Attacks  of  sweating  appeared 
during  what  the  patient  believed  was  influenza, 
and  her  daughter  became  subject  to  the  affec- 


170  Psychopathology  of  Hysteria 

tion  by  reason  of  psychic  contagion.  Three 
times  daily  at  a  fixed  hour,  and  continuing  for 
a  year,  as  much  as  300  c.  c.  of  perspiration  was 
lost  at  a  time.  These  attacks  were  unaccom- 
panied by  any  other  physical  or  psychic  dis- 
turbances. Both  patients  recovered  under  sug- 
gestive treatment.  (Miinch.  Med.  Woch.,  Aug. 
27,  1907.) 

With  hypnotic  suggestion  one  can  readily 
induce  attacks  of  profuse  hyperhidrosis ;  it 
suffices  to  cause  the  subject  to  believe  that  she 
is  becoming  disagreeably  warm. 

Some  neurologists  contend  that  there  is  no 
such  thing  as  hysteric  fever:  others  are  con- 
vinced that  fever  can  occur  as  a  manifestation 
of  hysteria.  Some  observers  who  limit  the 
symptomatology  of  hysteria  to  those  conditions 
which  can  be  reproduced  with  hypnotic  sug- 
gestion would  exclude  the  possibility  of  hysteric 
elevations  of  the  temperature.  At  all  events, 
Von  Krafft-Ebing  repeatedly  was  successful  not 
only  in  causing  the  temperature  of  lima  S.  to 
vary  as  much  as  2.5°  F.,  but  in  causing  the 
variations  to  occur  at  a  fixed  hour,  and  to  per- 
sist for  days  at  a  time.  Reverting  to  hysteria, 
Osier  declares  that  in  at  least  two  of  his  cases 
a  diagnosis  other  than  hysteric  fever  was  im- 
possible. In  one  of  these  the  temperature  rose 
to  102  or  103  every  afternoon  for  four  or  five 
years.  (Principles  and  Practice  of  Medicine, 
1902,  p.  1119.) 


Visceral  and  Circulatory  Derangements  171 

In  1858  a  girl  who  had  been  found  uncon- 
scious in  the  street  was  brought  to  Bamberger's 
clinic  in  a  delirious  state  with  a  tempera- 
ture of  106.7°  F.  The  diagnosis  was  declared 
to  be  either  typhoid  fever  or  miliary  tubercu- 
losis. The  following  morning  all  of  her  symp- 
toms had  disappeared;  she  was  well.  It  was 
found  that  having  been  jilted  by  her  lover  at  a 
dance  she  became  greatly  excited,  and,  while 
running  home,  had  fallen  unconscious  in  the 
street.     (Muench.  med.  Woch.,  No.  19,  1903.) 

George  L.  Walton  reports  a  case  of  hysteria 
in  which  a  temperature  of  105  was  noticed  as 
an  isolated  symptom  that  persisted  for  a  week 
and  then  gradually  dropped  to  the  normal  dur- 
ing the  course  of  several  months.  In  discussing 
this  case  Knapp  spoke  of  a  case  of  hysteric 
hemianagsthesia  and  hemiplegia  in  which  the 
temperature  varied  from  105  to  95.  and  Court- 
ney of  another  hysteric  whose  temperature  had 
been  100  to  lOOYo  for  several  years.  (Jour,  of 
Nerv.  and  Ment.  Dis.,  1907,  p.  266.) 

Following  an  attack  of  influenza  the  temper- 
ature of  one  of  my  cases  of  hysteria  continued 
at  99  to  100%  for  over  a  month  in  the  absence 
of  any  ascertainable  cause  for  the  elevation  and 
without  its  being  associated  with  any  other 
symptoms.  When  the  regular  use  of  the  ther- 
mometer was  discontinued  the  fever  immedi- 
ately disappeared. 

After  reporting  two  eases  of  hysteric  hyper- 


172  PsychopatJCology  of  Hysteria 

thermia  Von  Voss  concluded  that  elevation  of 
the  temperature  may  occur  as  a  manifestation 
of  hysteria  in  severe  cases,  and  that  it  often 
accompanies  convulsive  seizures.  (Deutsche 
Zeitschr.  fiir  Nervenheilkunde,  Band  30,  Heft 
3-4.) 

Naturally,  elimination  of  all  possible  causes 
for  fever  other  than  hysteria  is  difficult  if  not 
impossible,  but  careful  observation  in  these  and 
other  similar  cases  which  have  been  reported 
tend  to  justify  the  assumption  that  variations 
in  the  bodily  temperature  can  be  produced  by 
hysteria.  As  already  noted  the  fact  that  the 
temperature  has  been  altered  through  the 
agency  of  hypnotic  suggestion  by  more  than 
one  observer  tends  to  confirm  this  belief. 


CHAPTER  VI 

Psycho-Motor  Disorders 

PARALYSIS.  Other  than  through  the 
agency  of  accidental  occurrences  there 
is  no  reason  why  one  hysteric  should 
be  paralyzed,  another  afflicted  with 
convulsions,  and  a  third  contractured.  These 
conditions,  as  well  as  the  other  innumer- 
able manifestations  which  are  possible  in 
hysteria,  really  are  potential  in  every  case,  and 
for  that  reason  justly  they  may  be  denominated 
** accidents."  One  patient  has  psycholeptic 
attacks  and  another  paralysis  simply  because 
the  first  accidentally  was  exposed  to  psychic 
contagion  as  a  result  of  witnessing  an  epileptic 
attack,  and  the  second  is  paralyzed  because  he 
has  been  subjected  to  some  traumatism  which, 
in  his  opinion,  was  capable  of  inducing  paraly- 
sis. Casual  events  and  the  conceptions  of  the 
patient  determine  both  the  production  and  the 
character  of  the  various  manifestations. 

According  to  Ziehen  the  symptoms  of  hys- 
teria are  due  to  the  remarkable  vividness  with 
which  mental  representation  occurs  in  this  dis- 
ease; the  idea  of  paralysis  being  sufficient  to 
evoke  the  symptom.  As  the  idea  of  paralysis 
may  be  aroused  by  numerous  kinds  of  excita- 
tion so  the  symptom  superficially  may  appear 
to  be  widely  varied  in    its    mode    of  genesis. 

173 


174  Psych  opathology  of  Hysteria 

Wlien  a  patient  who  has  slept  with  the  head! 
pillowed  on  the  arm  develops  what  should  be  a 
transient  brachial  paralysis  the  condition  may 
become  fixed  and  continue  as  a  manifestation  of 
hysteria.  In  the  same  manner  monoplegia  may 
be  evolved  from  the  transient  motor  and 
sensory  symptoms  resulting  from  undue  main- 
tainance  of  an  extremity  in  a  constrained  posi- 
tion. In  either  instance  the  paralysis  should 
be  accompanied  with  anesthesia  because  the- 
fundamental  and  temporary  organic  motor  dis- 
turbance having  occurred  in  association  with 
numbness  both  of  these  symptoms  would  prob- 
ably become  fixed. 

As  the  effect,  too,  of  the  lay  conception  that 
paralysis  necessarily  must  produce  numbness, 
the  two  conditions  are  usually  found  together, 
and  their  boundaries  may  coincide  regardless 
of  differences  in  nerve  supply.  The  pathogenic 
influence  of  the  same  conception  is  noticeable 
in  those  patients  who  present  impairment  of 
strength  in  members  which  have  become  the 
seat  of  an9?sthesia  of  medical  origin.  For  in- 
stance, the  patient  is  unaware  of  any  disturb- 
ance of  sensation  or  of  muscular  power  until 
she  is  subjected  to  examination.  Then,  without 
being  associated  with  any  loss  of  strength, 
hemianagsthesia,  perhaps,  is  ''found."  Later 
she  returns  to  complain  of  muscular  weakness 
of  the  same  side  of  her  body. 

The  majority  of  paralyses  follow  traumatism,. 


Psycho-Motor  Disorders  175 

and  as  men  are  more  exposed  to  injury  than 
are  women,  it  is  not  surprising  that  this  symp- 
tom occurs  far  more  commonly  in  males.  In 
reference  to  traumatism,  one  should  bear  in 
mind  the  fact  that  the  "accidents"  of  hysteria 
are  dependent  upon  the  psychic  effects  of  an 
injury,  and  not  upon  its  physical  consequences. 
No  matter  how  severe  the  traumatism  may  have 
been  it  is  only  the  idea  of  injury  that  eventu- 
ates in  hysteric  paralysis  and  other  symptoms 
of  the  disease.  As  a  matter  of  fact,  in  cases  of 
hysteric  paralysis  following  injury^  it  is  not  at 
all  unusual  to  find  that  the  injury  was  but  a 
trivial  one.  Unless  deceived  by  the  apparent 
serious  import  of  the  symptom  the  layman  is 
inclined  to  attribute  such  cases  to  what  is  pop- 
ularly termed  a  vivid  iraagination,  or,  if  the 
case  happens  to  be  one  in  which  a  law  suit  is 
being  instituted,  the  interpretation  is  more  con- 
temptuous. 

Besides  those  patients  with  hysteric  paralyses 
originating  entirely  from  the  psychic  effects  of 
an  injury  not  infrequently  actual,  but  transi- 
tory, paralysis  due  to  traumatism,  or  pseudo- 
paralysis of  painful  injuries,  may  become  elab- 
orated and  fixed  as  hysteric  paralysis  that  con- 
tinues after  the  organic  cause  has  subsided. 
Thus,  paralysis  due  to  traumatic  neuritis,  or 
pseudo-paralysis  consequent  upon  the  pain  of  a 
sprain,  may  be  the  source  of  hysteric  paralysis. 

Two   cases  which    have    been    reported    by 


176  Psychopathology  of  Hysteria 

Prince  illustrate  very  nicely  the  genesis  of 
paralysis  from  negligible  injuries :  During  the 
Civil  War  a  round  shot,  after  having  knocked 
a  tin  dipper  from  the  hand  of  a  soldier,  passed 
between  his  elbow  and  his  side.  The  wind  of 
the  shot  threw  him  to  the  ground.  Upon  re- 
gaining consciousness,  twenty-four  hours  later, 
he  presented  the  same  symptoms,  he  declared, 
as  when  Prince  examined  him — decided,  but 
not  absolute,  paralysis  and  profound  anaesthesia 
of  the  whole  left  upper  extremity.  The  other 
patient  had  been  struck  and  rendered  uncon- 
scious by  some  large  missile  during  a  battle  of 
the  Civil  War.  His  blanket  roll  had  so  broken 
the  force  of  the  blow  that,  at  the  time,  the  only 
sign  of  injury  was  ecchymosis  below  the  left 
shoulder ;  yet  incomplete  hemiplegia  and  hemi- 
anagsthesia  had  developed  and  persisted. 
(Amer.  Jour,  of  the  Med.  Sciences,  July,  1892.) 
During  intense  excitement  a  normal  indi- 
vidual may  feel  that  his  legs  are  giving  away 
beneath  him.  Popularly  this  fact  is  well 
known;  hence  the  expression  "to  feel  weak  in 
the  knees."  Given  a  hysteric  person  who  has 
sustained  some  emotional  shock  during  which, 
among  other  reactions,  this  feeling  of  weakness 
occurred,  what  is  more  natural  than  the  devel- 
opment of  hysteric  paraplegia  as  a  souvenir  of 
the  incident  ?  It  is  the  evolution  of  the  physical 
symptoms  of  hysteria  from  psychic  stresses  that 
led  Freud  to  compare  them  with  the  monuments 


Psycho-Motor  Disorders  177 

which  are  erected  to  commemorate  important 
historical  events. 

The  idea  of  paraplegia  may  owe  its  origin  to 
the  effects  of  illness.  Anyone  who  has  been 
confined  to  bed  several  weeks  with  some  severe 
illness  is  more  or  less  completely  unable  to 
walk,  or  to  stand  alone,  when  he  first  rises  from 
bed.  This  actual  weakness  of  the  lower  ex- 
tremities may  continue  several  days  or  more, 
and.  in  a  hysteric,  it  may  persist  solely  as  a 
fixed  and  elaborated  s^Tuptom  of  hysteria.  In- 
deed, it  is  from  just  such  conditions  that  many 
of  the  manifestations  are  evolved :  for  all  have 
some  definite  exciting  cause.  Our  inability  to 
find  the  precise  reason  for  each  symptom  that 
every  patient  presents  is  only  evidence  that  our 
analyses  are  incomplete,  or  defective,  and  not 
that  such  symptoms  "just  happened." 

A  beautiful  example  of  the  manner  in  which 
an  emotional  shock — the  idea  of  injury  in  this 
case — alone  can  bring  about  paralysis  is  men- 
tioned by  Janet:  A  man  had  descended  upon 
the  running  board  of  a  railroad  coach  in  the 
attempt,  while  the  train  was  in  motion,  to 
change  compartments.  As  the  train  was  about 
to  enter  a  tunnel,  while  he  was  still  on  the  run- 
ning board,  the  idea  occurred  to  him  that  his 
left  side  would  be  crushed.  The  terror  aroused 
by  this  thought  caused  him  to  faint,  and  he  fell 
back  into  the  compartment.  Notwithstanding 
that  physically  he    was   uninjured,    left  hemi- 


178  Psychopathology  of  Hysteria 

plegia  developed.     (Major  Symptoms  of  Hys- 
teria, p.  141.) 

Whatever  the  cause,  paralysis  and  other  ''ac- 
cidents ' '  of  hysteria  may  not  appear  at  once : 
there  may  be  an  intervening  period  of  auto- 
suggestion which  may  last  hours  or  days, 
and  even  weeks.  During  the  interval  the  pa- 
tient may  not  be  consciously  brooding  over 
the  memories  of  the  injury,  for  these  memories 
may  have  been  dissociated  from  consciousness. 
Later  some  entirely  different  event  may  arouse 
them  into  pathologic  activity  with  the  conse- 
quent production  of  a  paralysis,  an  amaurosis, 
or  some  other  manifestation.  So  there  may 
occur  what  may  be  termed  a  delayed  reaction, 
or  a  reaction  by  substitution.  Instead,  then,  of 
hysteric  paralysis  being  evolved  from  an  in- 
jury which  might  be  expected  to  produce  this 
symptom,  the  patient  may  develop,  for  example, 
amaurosis  because  the  mental  shock  set  into 
activity  the  dissociated  memories  of  some  other 
experience  whose  logical  result,  amaurosis,  re- 
mained latent. 

The  diminution  of  muscular  force  which  is 
met  with  so  commonly  during  the  examination 
of  hysteric  patients  cannot  be  regarded  as  in- 
complete paralysis  for  the  reason  that  it  is  due 
entirely  to  the  interference  of  attention  with 
the  muscular  efforts  which  are  being  tested. 
Dynamometric  investigation  of  hysterics  shows 
that  the  gripping  force  apparently  is  greatly 


Psycho-Motor  Disorders  179 

impaired  in  over  90%  of  the  cases.  But  when 
these  same  patients  shake  hands,  or  when  they 
lift  objects  which  require  considerable  gripping 
force,  one  sees  at  once  that  the  dynamometric 
readings  cannot  be  considered  indicative  of  the 
amount  of  strength  which  the  patients  really 
possess. 

In  its  distribution  hysteric  paralysis  may  af- 
fect a  single  muscle,  or  group  of  muscles,  or  it 
may  assume  the  form  of  a  monoplegia,  a  hemi- 
plegia, or  a  paraplegia.  Though  the  paralysis 
may  be  complete  cases  are  rarely  observed  in 
which  the  patient  is  totally  unable  to  use  the 
affected  part.  Except  its  tendency  to  be  asso- 
ciated with  anaesthesia,  hysteric  paralysis  fre- 
quently occurs  as  an  isolated  manifestation. 
Particularly  is  this  true  when  the  symptom  is 
consequent  upon  traumatism,  and  when  it  oc- 
curs in  males. 

In  those  confirmed  cases  of  the  hysteric  habit, 
or  of  hysteric  malingering  in  which  the  disease 
has  become  but  a  useful  means  to  an  end,  or  in 
which  the  patient  appears  to  take  great  pleas- 
ure in  her  numerous  ailments  and  who  occupies 
herself  agreeably  in  going  from  one  physician 
to  another  or  from  this  clinic  to  that,  hysteric 
paralysis  may  be  only  one  symptom  of  an  ex- 
tensive repertoire.  In  contradistinction  to  this 
type  of  patient  is  the  manner  in  which  paralysis 
is  regarded  by  the  patient  with  pure  hysteria. 
Such  a  patient  is  often  quite  contented  to  per- 


180  Psychopathology  of  Hysteria 

mit  her  paralysis  to  continue  undisturbed,  and 
the  interference  of  a  physician  may  be  looked 
upon  with  indifference,  or  it  may  provoke 
active  antagonism.  She  tranquilly  ignores  what 
ordinarily  is  considered  to  be  a  grave  symptom, 
and  whether  merely  inconvenienced,  or  actually 
incapacitated,  she  is  totally  unconcerned  about 
her  condition. 

Inasmuch  as  hysteric  paralysis  is  the  conse- 
quence of  dissociation  of  the  ability  consciously 
to  evoke  motor  activity  in  the  affected  part  there 
should  not  be  any  interference  with  the  per- 
formance of  automatic  or  subconscious  acts.  Ac- 
cordingly, not  only  should  we  expect,  but  actu- 
ally we  find,  that  the  paralysis  disappears  dur- 
ing sleep,  hysteric  seizures,  and,  in  fact,  when- 
ever the  usual  state  of  consciousness  of  the 
patient  is  in  abeyance.  The  somnambulistic 
attacks  of  one  of  Janet's  cases  demonstrate  the 
manner  in  which  paralysis  disappears  during 
the  course  of  subconscious  states.  By  reason  of 
hysteric  paraplegia  this  patient  was  confined  to 
bed.  At  night,  however,  he  jumped  out  of  bed, 
and,  while  holding  his  pillow  in  the  belief  that 
it  was  his  child  whom  he  was  saving  from  the 
hands  of  his  mother-in-law,  he  ran  out  of  the 
room  and  into  the  court-yard.  Then  he  climbed 
to  the  roof  of  the  hospital.  Upon  being  awak- 
ened both  of  his  legs  again  became  paralyzed, 
and  it  was  necessary  to  carry  him  back  to  his 
bed. 


Psycho-Motor  Disorders  181 

As  the  usual  state  of  consciousness  of  a  patient 
is  in  abeyance  during  profound  hypnosis  one 
should  be  able,  through  the  agency  of  hypnotic 
suggestion,  to  secure  free  use  of  muscles  which 
are  the  seat  of  hysteric  paralysis.  By  this  means 
not  only  can  one  demonstrate  the  psychic  nature 
of  hysteric  paralysis  and  therefore  differentiate 
the  affection  from  one  which  is  organic,  but  it  is 
possible  also  to  remove  the  symptom. 

In  most  cases  the  diagnosis  is  a  simple  matter 
if  one  studies  both  the  symptom  and  the  patient. 
In  the  absence  of  positive  differentiating  features 
pertaining  to  the  paralj^sis  itself,  the  discovery 
of  other  evidences  of  hysteria  cannot  be  used  as 
the  basis  for  a  diagnosis  because  of  the  fre 
quency  with  which  hysteria  and  organic  disease 
coexist.  The  character  of  the  symptom  and  the 
absence  of  qualities  essential  to  organic  paralysis 
alone  must  be  considered. 

Like  the  distribution  of  psychic  anaesthesias 
the  muscles  involved  in  hysteric  paralysis  may 
not  correspond  to  nerve  supply.  Except  the  in- 
considerable wasting  of  disuse  that  may  occur 
in  long  standing  cases  there  is  not  any  true 
atrophy  of  the  affected  part,  nor  are  there  any 
changes  in  the  electrical  reactions.  In  cases  of 
hysteric  hemiplegia  the  face  is  rarely  involved. 
On  the  basis  of  Briquet's  60  cases  of  hemiplegia 
examined  before  1859  considerable  stress  has 
been  placed  upon  the  statement  that  the  left  side 
is  affected  three  times  as  frequently  as  the  right. 


182  Psychopathology  of  Hysteria 

Ernest  Jones,  however,  found  that  the  right 
side  was  the  seat  of  hemiplegia  in  54.2%  of  277 
cases  reported  since  1880.  (Rev.  Neurol,  Mar.  15, 
1908.) 

The  gait  of  hysteric  hemiplegia  differs  greatly 
from  that  of  organic  disease.  Wlien  organic  the 
patient  sT\ings  the  paralyzed  leg  forward  so  that 
the  anterior  inner  surface  of  the  foot  describes 
an  arc  on  the  floor;  the  hysteric  drags  her  par- 
alyzed limb  behind  her  jast  as  one  would  expect 
in  consideration  of  her  conception  of  paralysis 
and  her  lack  of  knowledge  of  how  a  case  of  or- 
ganic hemiplegia  really  should  walk.  The  or- 
ganic hemiplegic  wears  out  the  inner  aspect  of 
the  toe  of  his  shoe  while  the  hysteric's  shoe  is 
more  apt  to  be  damaged  most  at  the  point. 

When  we  exert  resistance  to  the  muscular  ef- 
forts of  a  patient  with  incomplete  hysteric 
paralysis,  and  when  we  study  the  manner  in 
which  the  non  paralyzed  hysteric  grips  the  dy- 
namometer, we  find  notwithstanding  that  the 
patient  appears  to  be,  and  is,  exerting  consid- 
erable strength,  and  that  he  fairly  trembles  in  his 
efforts  to  produce  still  more  forcible  muscular 
contraction,  yet  the  results  are  almost  nil.  The 
explanation  of  this  apparent  diminution  of 
strength,  and  of  the  seeming  disproportion  be- 
tween muscular  effort  and  its  effects,  lies  in  the 
fact  that  the  contraction  of  the  muscles  which 
are  being  tested  is  almost  neutralized  by  similar 
activity  of  their  opponents. 


Psycho-Motor  Disorders  183 

Of  the  utmost  diagnostic  importance  is  the 
condition  of  the  tendon  reflexes.  Regardless  of 
the  presence  or  absence  of  paralysis  the  patellar 
reflexes  are  slightly,  but  truly,  exaggerated  in 
almost  all  cases  of  hysteria.  Occasionally  the  re- 
flex may  appear  to  be  greatly  exaggerated,  but 
as  this  exaggeration  usually  resembles  an  inten- 
tional muscular  action  it  cannot  be  mistaken  for 
that  caused  by  organic  spastic  paralysis.  On  the 
other  hand,  the  knee- jerks  may  be  greatly  in- 
hibited, or  even  caused  to  appear  to  be  lost  when 
the  patient  concentrates  her  attention  upon  the 
tests  and  contracts  the  muscles  of  the  thigh. 
Those  who  have  attempted  to  demonstrate  a  nor- 
mal knee-jerk  in  students  have  encountered  this 
difficulty.  Except  these  kno^^ra  variations  of  the 
patellar  reflex  it  may  be  asserted  that  absolute 
loss,  or  that  true  increase  to  an  extent  that  is 
observed  in  upper  motor  neuron  type  of  paraly- 
sis, cannot  occur,  in  a  typical  manner  as  the  re- 
sult of  uncomplicated  hysteria.  Momentary  loss 
of  the  knee-jerks,  however,  occurred  regularly, 
during  the  attacks  of  hysteric  petit  mal  of  a 
patient  reported  by  Putnam.  (Personal  Expe- 
rience with  Freud's  Psychoanalytic  Method, 
Jour,  of  Nervous  and  Mental  Diseases,  1910,  p 
670.) 

It  is  stated  that  2%  of  presumably  normal  in- 
dividuals do  not  possess  knee-jerks.  Now,  if 
hysteria  developed  in  any  of  these  it  might  be 
thought  that  the  absence  of  the  reflex  was  due 
to  hysteria. 


184  Psychopathology  of  Eystena 

In  uncomplicated  hysteria  it  is  not  unusual  to 
elicit  a  pseudo-clonus,  which,  unlike  true  clonus, 
is  not  sustained  and  is  semi-voluntary.  In  ex- 
ceptional instances  typical  ankle  clonus  may  oc- 
cur, but  I  have  never  been  able  to  discover  this 
phenomenon  among  any  of  my  cases  until  re- 
cently. The  patient  was  a  major  hysteric  who 
had  been  under  observation  at  intervals  for  four 
years.  Lately  the  usual  type  of  hysteric  hemi- 
plegia developed  and  there  could  not  be  any 
doubt  concerning  the  absence  of  any  organic 
lesion.  During  one  examination  a  true  organic 
type  of  sustained  ankle  clonus  was  found  on  the 
paralyzed  side,  but  there  were  no  other  of  the 
physical  signs  of  organic  disease.  The  follow- 
ing day,  while  demonstrating  the  patient  before 
a  section  of  students,  it  was  impossible  to  elicit 
even  the  faintest  tendency  towards  clonus. 

In  a  case  of  hysteric  convulsive  seizures  re- 
ported by  Heard  and  Diller  the  patient  had 
bilateral  sustained  clonus  which  disappeared 
after  two  weeks.  The  patient  completely  recov- 
ered under  anti-hysterical  treatment.  The  clonus 
was  believed  to  be  entirely  hysteric  in  origin,  and 
in  commenting  on  the  case  the  opinion  is  ex- 
pressed that  ankle  clonus  is  not  necessarily  in- 
dicative of  organic  disease ;  that  it  can  develop  as 
a  manifestation  of  hysteria.  (Ankle  Clonus  in 
a  Case  of  Major  Hysteria,  Jour,  of  Nervous  and 
Mental  Disease,  1910,  p.  239.) 

Like  the  knee-jerks,  the  Achilles  reflex  cannot 


Psycho-Motor  Disorders  185 

be  abolished  by  hysteria,  and,  excluding  doubt- 
ful reactions  to  plantar  irritation,  it  is  improb- 
able, too,  that  a  typical  Babinski  reaction  can 
be  caused  by  the  disease. 

As  many  cases  of  multiple  sclerosis  early  in 
their  course  have  been  mistaken  for  hysteria,  and 
as  clonus,  exaggerated  knee-jerks,  and  the 
Babinski  sign  are  common  symptoms  of  this  dis- 
ease, it  may  happen  that  true  organic  changes 
in  the  reflexes  may  be  discovered  in  cases  of 
what  appear  to  be  hysteria  but  which,  in  reality, 
as  later  events  show,  are  cases  of  multiple 
sclerosis. 

There  are  other  organic  diseases,  too,  which 
may  be  overlooked,  and  whose  alterations  in  the 
reflexes  may  be  ascribed  to  what  is  a  superim- 
posed hysteria. 

Probably  most  authorities  believe  that  the 
reflex  changes  typical  of  organic  disease  cannot 
be  produced  by  hysteria.  On  the  other  hand, 
well  attested  cases  of  supposedly  uncomplicated 
hysteria  have  been  reported  by  such  observers 
as  Nonne,  Marie,  Dejerine,  Van  Gehuchten,  etc., 
in  which  the  Babinski  reflex,  clonus,  and  absent 
or  exaggerated  patellar  and  Achilles  reflexes 
have  been  found.  Even  if,  as  these  authorities 
contend,  such  alterations  of  the  reflexes  rarely 
can  occur  as  manifestations  solely  of  hysteria, 
the  discovery  of  these  changes  in  a  case  of  the 
disease  argues  most  strongly  for  the  coexistence 
of  organic  nervous  disease. 


186  Psychopathology  of  Hysteria 

Of  interest  are  the  results  of  Knapp's  inquiry 
into  the  condition  of  the  reflexes  in  100  cases  of 
hysteria  presenting  a  difference  in  sensibility  in 
the  lateral  halves  of  the  body.  He  found  some 
exaggeration  of  the  tendon  reflexes  in  86  cases 
and  spurious  ankle  clonus  in  7  cases.  Of  57 
cases  presenting  unequal  exaggeration  of  the 
tendon  reflexes  the  increase  was  found  twice  as 
often  on  the  ansesthetic  side  as  on  the  opposite 
one.  True  ankle  clonus,  the  Babinski  sign,  and 
absence  of  the  patellar  reflexes  were  not  observed 
in  any  of  the  cases.  Unlike  the  tendon  reflexes 
impairment,  or  loss,  of  the  skin  reflexes  of  an 
anaesthetic  part  is  not  uncommon.  In  24  cases 
out  of  51  Knapp  found  the  abdominal  reflex 
to  be  involved  in  this  manner.  (Jour,  of  Nerv. 
and  Ment.  Dis.,  1910,  p.  93.) 

A  valuable  means  of  differentiation  between 
organic  and  hysteric  hemiplegia  is  afforded  by 
Hoover's  complemental  opposition  sign.  (Jour 
of  the  A.  M.  A.,  1908,  2,  746.)  When  a  normal 
individual  who  is  lying  upon  his  back  elevates 
one  extended  lower  extremity  the  downward 
pressure  of  the  opposite  heel  is  increased,  and 
when  one  extended  lower  extremity  is  pressed 
down  with  some  force,  the  downward  pressure  of 
the  contralateral  limb  is  lessened.  In  cases  of 
organic  hemiplegia  attempts  to  elevate  the 
paralyzed  limb  result  in  increased  downward 
pressure  of  the  opposite  heel,  even  though  the 
paralyzed  extremity  does  not  move.    Also,  eleva- 


Psycho-Motor  Disorders  187 

tion  of  the  extended  normal  limb  is  accompan- 
ied by  an  amount  of  contralateral  downward 
pressure  that  is  proportionate  to  the  degree  of 
paralysis.  If  the  hemiplegia  is  hysteric  in  origin 
the  attempt  to  raise  the  paralyzed  limb  does  not 
increase  the  downward  pressure  of  the  opposite 
heel,  while  elevation  of  the  normal  limb 
does  produce  complemental  opposition  of  the 
paralyzed  side.  In  the  same  manner  the  com- 
plemental opposition  sign  may  be  elicited  by 
having  the  patient  press  the  extremity  down 
upon  the  surface  upon  which  he  is  lying,  in- 
stead of  raising,  or  attempting  to  raise,  the  limb. 

In  testing  patients  with  moderate  organic 
ataxia  (Jour,  of  the  A.  M.  A.,  1909,  1,  1234.) 
Hoover  found  that  the  amount  of  complemental 
opposition  is  increased  whether  the  patient 's  eyes 
are  open  or  closed.  But  if  the  ataxia  is  extreme 
complemental  opposition  is  exaggerated  when  the 
patient's  eyes  are  open;  w^hile  it  disappears  en- 
tirely if  his  eyes  are  closed;  the  patient  then 
reacting  like  the  hysteric,  or  the  malingerer. 

As  cited  by  Hoover,  Lhermitte  found  that 
when  paralysis  of  one  lower  extremity  has  been 
induced  by  means  of  hypnotic  suggestion  the  va- 
riations of  complemental  opposition  are  the  same 
as  those  observed  in  hysteria  and  malingering. 
In  experimenting  with  hypnotic  subjects  I  have 
verified  this  when  the  suggested  paralysis  was 
complete;  otherwise,  complemental  opposition 
may  be  the  same  as  that  observed  Tidth  organic 


188  Psychopathology  of  Hysteria 

paralysis.  The  same  holds  true  of  hysteria.  In 
either  hysteric  or  hypnotic  hemiplegia  the 
absence  of  complemental  opposition  depends  en- 
tirely upon  the  fact  that  the  patient  is  so  firmly 
convinced  of  the  reality  of  her  paralysis  that  she 
really  does  not  attempt  to  raise  the  limb. 

When  hysteric  hemiplegia  is  spastic  then  com- 
plemental opposition  occurs,  but  the  amount  ex- 
hibited when  the  patient  attempts  to  lift  the 
paralyzed  limb  is  not  as  great  as  when  the  nor- 
mal one  is  elevated.  The  same  result  is  obtained 
when  testing  subjects  in  whom  the  condition  has 
been  produced  by  suggestion.  The  explanation 
is  obvious.  Hysteric  or  hypnotic  spastic  paraly- 
sis depends  upon  a  more  or  less  constant  rigidity, 
and  when  the  patient  strives  voluntarily  to  use 
one  group  of  muscles  there  is  a  corresponding 
increase  in  the  amount  of  contraction  of  the 
opposing  group  with  consequent  increase  in 
rigidity.  Now,  if  the  patient  attempts  to  elevate 
the  paralyzed  limb  the  opposing  group  of 
muscles  contract  sufficiently  to  prevent  the  limb 
from  being  raised  but  not  enough  to  maintain 
the  same  amount  of  downward  pressure  that 
had  been  produced  by  the  weight  of  the  limb 
itself.  This  result  would  be  expected  because 
the  patient's  conception  of  her  paralysis  mere- 
ly prevents  elevation  of  the  limb  and  variations 
in  the  downward  pressure  due  to  its  weight  do 
not  enter  into  her  subconscious  calculations. 
Consequently,  complemental  opposition  of  the 


Psycho-Motor  Disorders  189 

other  extremity  occurs  to  a  degree  sufficient  to 
counter-balance  this  decrease  in  the  weight  of 
the  affected  extremity. 

In  the  examination  of  modifications  of  com- 
plemental  opposition  Zenner  (Jour,  of  the  A.  M. 
A.,  1908,  2,  1309,)  avers  that  it  is  easier  to  de- 
tect contraction  of  the  semitendinosus,  the  semi- 
membranosus, and  the  biceps  muscles  than  it  is 
to  appreciate  variations  of  the  downward  pres- 
sure of  the  heel. 

Another  sign  which  is  dependent  upon  com- 
plemental  opposition  has  been  described  by 
Raimiste  (Rev.  Neurol.,  Feb.  1909.)  While  the 
patient,  with  both  lower  extremities  abducted,  is 
lying  upon  a  smooth,  firm  surface  the  physician 
requests  him  to  draw,  but  not  to  lift,  the  normal 
extremity  over  towards  the  paralyzed  one,  and, 
at  the  same  time,  the  physician  forcibly  opposes 
"the  movement.  If  the  hemiplegia  is  organic, 
abduction  of  the  paralyzed  limb  occurs.  In  like 
manner  abduction  of  the  paralyzed  member 
takes  place  when  both  lower  extremities  are  in 
apposition  and  the  normal  one  forcibly  is  pre- 
sented from  being  separated  from  its  fellow. 

A  type  of  progressive  muscular  atrophy  be- 
ginning in  the  iliopsoas  muscles  has  been 
described  by  Thomas  Buzzard,  who  points  out 
the  difficulty  of  differentiating  the  condition 
from  some  kinds  of  hysteric  paraplegia.  (On 
the  Simulation  of  Hysteria  by  Organic  Disease 
of  the  Nervous  System,  1891,  p.  5.)     In  cases 


190  Psychopathology  of  Hysteria 

presenting  this  unusual  variety  of  onset  of  pro- 
gressive muscular  atrophy  the  patient  com- 
plains of  weakness  in  the  lower  extremities, 
together  with  difficulty  in  ascending  stairs,  in 
walking  uphill,  or  in  rising  from  a  chair,  yet, 
if  the  disease  is  confined  to  the  iliopsoas 
muscles,  examination  shows  that  the  reflexes 
and  electrical  reactions  which  are  capable  of 
being  elicited  are  normal,  and  that  not  any 
atrophy  is  in  evidence.  The  diagnosis  in  such 
cases  depends  upon  the  character  of  the  motor 
disturbance  and  upon  the  absence  of  signs  of 
hysteria.  If  the  disease  has  spread  to  the 
muscles  of  the  thigh  then  the  loss  of  the 
patellar  reflexes,  changes  in  the  electrical  re- 
actions, and  the  appearance  of  atrophy,  make 
the  recognition  of  the  disease  an  easy  matter. 
A  paralysis  which  is  accidentally  suggested 
upon  a  patient  owes  its  continued  existence  to 
the  patient's  belief  in  his  inability  to  activate 
the  affected  muscles.  Consequentlj^,  if  he  can 
be  induced  to  believe  that  paralysis  no  longer 
exists,  the  symptom  will  disappear  at  once,  or 
if  he  can  be  convinced  that  some  form  of  treat- 
ment is  going  to  "cure"  the  paralysis,  then 
the  condition  should  vanish  either  suddenly  or 
gradually.  On  the  other  hand,  if  the  patient 
does  not  receive  any  treatment  the  paralysis 
wdll  continue  until  some  accidental  occurrence 
causes  him  to  recover  the  use  of  the  affected 
muscles  either  by  inducing  him  to  expect  recov- 


Psycho-Motor  Disorders  191 

ery,  or  suddenly  by  arousing  the  conviction 
that  the  paralysis  no  longer  exists. 

It  is  only  by  reason  of  the  state  of  expectancy 
which  is  induced  in  a  devout  hysteric  that  sin- 
cere faith  in  the  miraculous  curative  virtues  of 
a  relic  is  capable  of  producing  immediate  cure 
of  paralysis,  amaurosis,  etc.  Each  shrine  has 
its  quota  of  crutches  which  were  discarded  by 
cases  of  hysteric  paralysis  that  were  cured. 
For  the  same  reason  any  worthless  patent  medi- 
cine, electric  belts,  tractors,  magnets,  and  kin- 
dred ''therapeutic"  agents  vdll  be  effectual, 
providing  that  the  patient  has  sufficient  faith  in 
the  means.  "With  most  of  the  monosympto- 
matic  cases  it  is  a  question  only  of  combatting 
one  belief  with  another,  and  the  stronger  one 
wins. 

Recent  hysteric  paralysis  usually-  is  very 
amenable  to  treatment.  On  the  contrary,  long 
continued  paralysis  tends  indefinitely  to  per- 
sist, regardless  of  treatment.  Hemiplegia  and 
two  instances  of  brachial  monoplegia  had  con- 
tinued for  29,  28,  and  30  years  respectively,  in 
the  three  old  soldiers  with  hysteric  paralysis 
reported  by  Prince. 

Systematized  Paralysis.  Paralysis  is  sys- 
tematized when  it  exists  only  for  the  conscious 
performance  of  certain  acts;  other  forms  of 
conscious  activity  with  the  same  groups  of 
muscles  not  being  impaired.  Through  the 
agency  of  hypnotic  suggestion  not  only  can  we 


192  Psychopathology  of  Hysteria 

produce  ordinary  psychic  paralysis,  but  sys- 
tematized paralysis  also  can  be  created;  and 
either  of  such  types  present  all  the  character- 
istics of  those  due  to  hysteria.  If  we  tell  a 
hypnotized  subject  that  he  is  unable  to  walk 
and  then  by  means  of  post  hypnotic  suggestion 
cause  the  resulting  condition  to  persist  after 
the  hypnotic  state  has  been  removed,  different 
types  of  astasia-abasia  can  be  evolved  which 
cannot  be  differentiated  from  the  varieties  met 
with  in  hysteria.  Let  us  consider,  then,  that 
hysteric  paralysis  and  systematized  paralysis  are 
the  consequence  of  dissociation  from  conscious- 
ness either  of  all  forms,  or  of  particular  kinds 
of  motor  functions  in  a  part  or  parts,  and  that 
this  dissociation  is  affected  by  autosuggestion. 

Astasia-Abasia.  In  the  affection  kno^n  as 
astasia-abasia  the  patient  is  unable  normally 
to  stand  or  to  walk  without,  however,  any  other 
kinds  of  activity  of  the  lower  extremities  being 
impaired.  Total  inability  to  walk  is  occasioned 
when  the  condition  is  highly  developed.  More 
frequently  some  peculiar  type  of  gait  is  pos- 
sible. Except  as  the  result  of  abnormal  idea- 
tion astasia-abasia  would  be  impossible.  It  is 
only  a  psychopathic  state  which  is  capable  of 
producing  inability  to  walk  in  a  patient  whose 
muscles  are  not  paralyzed  or  ataxic  and  who, 
perhaps,  is  able  to  run  and  to  dance. 

To  illustrate  a  mode  of  genesis  of  astasia- 
abasia,  and  at  the  same  time  to  demonstrate  the 


Psycho-Motor  Disorders  193 

importance  of  autosuggestion  in  the  produc- 
tion of  symptoms  of  hysteria,  there  is  no  better 
instance  than  that  afforded  by  Prince's  B.  C.  A. 
case  of  dissociation  of  personality.  (Jour,  of 
Abnormal  Psych,,  vol.  3,  p.  331.)  As  person- 
ality C,  the  patient  had  witnessed  the  peculiar 
gait  of  a  patient  with  astasia-abasia.  The  co- 
conscious  personality  B,  (what  might  be  termed 
an  emancipated  subconsciousness)  became  in- 
terested in  the  condition,  and  later,  while 
thinking  deeply  on  the  subject  and  wondering 
how  it  would  feel  if  she  were  afflicted  with  the 
same  infirmity,  personality  C  became  much 
excited  and  the  condition  developed. 

Like  paraplegia,  astasia-abasia  may  develop 
from  the  transitory  difficulty  in  standing,  or 
walking,  that  a  hysteric  may  experience  after 
having  been  confined  to  bed  for  a  number  of 
days  by  some  acute  illness. 

Mutism.  Hysteric  mutism  is  the  most  in- 
teresting of  the  manifestations  due  to  system- 
atized paralysis.  It  may  be  looked  upon  as  a 
S3^stematized  paralysis  because  the  articulatory 
muscles  may  be  affected  only  for  speech.  The 
symptom  is  decidedly  more  frequent  in  males 
than  in  females,  and  often  it  occurs  as  a  more 
or  less  isolated  physical  manifestation.  As 
noted  in  the  section  devoted  to  audition,  hys- 
teric mutism  may  be  associated  with  psychic 
deafness.  Having  heard  of  deaf  and  dumb 
asylums  and  of  the  deaf  and  dumb  the  two  sen- 


194  Psychopathology  of  Hysteria 

sory  deficits  are  rather  intimately  associated  in 
the  minds  of  laymen.  As  a  consequence  of 
this  conceptual  relationship  a  hysteric  layman 
who  becomes  deaf  may  also  develop  mutism,  or 
vice  versa.  Another  mode  of  genesis  is  by 
means  of  fixation  and  elaboration  of  an  aphonia 
which  was  symptomatic  of  some  transient  local 
inflammation. 

Temporary  disturbance,  or  even  total  sup- 
pression, of  speech  is  a  normal  accompaniment 
of  intense  excitement.  An  angry  man  often 
stutters  out  his  rage,  or  is  rendered  speechless 
for  a  brief  period.  The  tendency  of  hysteria 
to  appropriate  whatever  suggests  itself  during 
periods  of  emotional  excess,  and  to  elaborate 
normal  reactions,  may  eventuate  in  the  devel- 
opment of  mutism,  or  of  other  speech  defects, 
from  just  such  a  transitory  difficulty.  For  ex- 
ample, a  patient  reported  by  0.  S.  Hubbard, 
(Jour,  of  the  Kansas  Med.  Soc,  1908,  p.  451) 
had  become  angry  and  much  excited.  Mutism 
developed  the  evening  of  the  same  day;  sev- 
eral hours  after  he  had  expressed  the  opinion 
that  soon  he  would  be  unable  to  talk,  ^y 
means  of  suggestion,  bitter  medicine,  and  mas- 
sage of  the  neck,  speech  was  caused  to  return 
the  following  day. 

Like  other  phenomena  of  the  disease  the 
symptom  may  be  paroxysmal  or  constant; 
paroxysms  being  aroused  by  association  of 
ideas.     The  attacks  of  mutism  occurring  in  one 


Psycho-Motor  Disorders  195 

patient  were  induced  onl}^  by  quarrels,  and  it 
was  found  that  some  few  years  ago  the  initial 
disturbance  followed  a  quarrel  with  her 
brother.  In  her  early  childhood  another  pa- 
tient had  fallen  from  a  tree  with  the  conse- 
quence that  a  prolonged  attack  of  mutism  oc- 
curred. During  the  succeeding  twenty-five  or 
thirty  j^ears  she  had  been  subject  to  paroxysms 
of  mutism  that  occurred  about  two  or  three 
times  a  year  and  which  continued  for  a  few 
weeks ;  the  longest  having  lasted  three  months. 
Bach  of  the  attacks  followed  some  exciting 
incident,  and  the  mutism  was  absolute — she  was 
unable  to  talk,  whisper,  or  even  to  whistle. 
Being  accustomed  to  the  seizures  she  neither 
feared  nor  worried  about  them. 

An  account  of  an  interesting  case  of  mutism 
that  occurred  during  the  seventeenth  century 
was  discovered  by  Jahnel  in  an  old  book.  Fol- 
lowing a  narrow  escape  from  drowning  the 
patient,  aet.  10,  developed  complete  mutism. 
For  fifty  years  he  was  able  to  speak  only 
from  noon  until  one  o'clock,  and  even 
though  no  clock  was  at  hand  he  was  accu- 
rate to  a  minute  in  his  determination  of  these 
hours.  Except  two  or  three  days  before  his 
death  only  twice  was  he  known  to  speak  at 
other  hours,  and  on  both  of  these  occasions  he 
was  ill  from  fever.  (Nerologisches  Central- 
blatt,  June  1,  1908,  p.  512.) 


196  Psychopathology  of  Hysteria 

The  psychic  effects  of  traumatism  and  the 
occasional  resistance  of  hysterical  symptoms  to 
treatment  is  shown  in  a  case  reported  by  J.  K. 
Mitchell.  (Jour,  of  Nerv.  and  Ment.  Dis.,  1907, 
p.  253.)  In  a  male  of  twenty-two  years  abso- 
lute mutism  succeeded  a  stuporous  condition 
which  had  been  induced  by  the  psychic  stress 
occasioned  by  contact  with  a  live  wire,  though 
no  other  physical  effects  than  a  small  brush 
burn  of  the  face  were  discovered.  Once  dur- 
ing the  course  of  the  mutism  the  patient  was 
known  unconsciously  to  have  uttered  a  few 
words,  and,  on  another  occasion,  he  talked  in 
his  sleep.  Local  faradism,  injection  of  strych- 
nine, suggestion  during  a  state  of  light  hyp- 
nosis, general  anaesthesia,  and  attempts  at  vocal 
re-education  were  unsuccessful  in  causing  the 
return  of  his  speech.  Fifteen  months  after  the 
onset  of  mutism  recovery  occurred  spontan- 
eously during  a  theatrical  crisis. 

On  recovering  consciousness,  after  having 
been  injured,  one  of  Bailey's  patients  had  mut- 
ism in  addition  to  other  major  symptoms  of 
hysteria.  Many  months  later  he  was  much 
alarmed,  after  a  second  accident,  to  find  that 
he  was  talking  to  himself — the  mutism  had  dis- 
appeared. The  diagnosis,  traumatic  hysteria, 
was  considered  incontestable.  (Diseases  of  the 
Nervous  System  Resulting  from  Accident  and 
Injury,  1906,  p.  448.) 

In  the  normal  person  a  nightmare   usually 


Psycho-Motor  Disorders  197 

causes  a  sense  of  depression  during  the  follow- 
ing day.  In  our  relations  with  psychopathic 
individuals  it  is  not  at  all  unusual  to  observe 
that  incidents  of  dreams  have  been  carried 
over  into  the  waking  state.  One  of  Prince's 
cases  serves  nicely  to  illustrate  this  mode  of 
genesis  of  symptoms.  (Jour,  of  Abnormal 
Psychology,  vol.  5,  p.  139.)  During  a  terrify- 
ing dream  the  patient  tried  to  call  to  her 
mother,  and,  as  usually  is  the  case  during 
dreams,  she  was  unable  to  speak.  After  wak- 
ing she  could  only  whisper,  and  the  complete 
aphonia  persisted  until  relieved  by  suggestion. 

Hysteric  mutism  may  be  interpreted  as  a 
massive  dissociation  from  consciousness  of  the 
faculty  of  vocal  expression  of  language.  When 
mutism  is  systematized  it  may  be  dependent 
either  upon  inability  to  articulate,  though  inter- 
nal language  is  unaffected,  or  upon  dissociation 
of  the  memories  of  certain  kinds  of  words.  The 
defect  in  the  latter  instance  is  more  properly 
classified  as  a  systematized  amnesia. 

Like  most  other  symptoms  of  the  disease  all 
the  varieties  of  mutism  readily  can  be  repro- 
duced by  means  of  suggestion.  And  whether 
the  affection  be  caused  by  hysteria  or  by  inten- 
tional suggestion,  it  is  the  product  of  a  fixed 
idea.  The  patient  sincerely  believes  that  he  is 
unable  to  speak,  and,  therefore,  he  does  not 
voluntarily  try  to  do  so.  Or,  if  at  the  instiga- 
tion of  others  he  does  attempt  to  speak,  his 


198  Psychopathclogy  of  Hysteria 

efforts  are  vitiated  by  his  conviction  that  they 
will  fail.  In  other  words,  no  matter  how 
earnest  the  patient  may  seem,  his  attempts  to 
speak  necessarily  must  fail  by  reason  of  the 
autosuggestion  of  failure  that  is  implied  by 
his  lack  of  conviction  in  their  success.  Any 
method,  then,  which  is  capable  of  arousing  the 
patient's  belief  in  his  ability  to  speak  should 
be  successful  in  the  treatment  of  this  condition, 
and  it  is  this  fact  which  enables  the  believer 
in  Christian  Science,  or  in  faith  cure,  or  in 
patent  medicine,  to  be  cured  by  these  supposed 
therapeutic  agents.  The  fact  that  they  do  cure 
justifies  the  use  of  the  principle  upon  which 
they  are  based ;  namely,  suggestion. 

Besides  mutism  numerous  speech  defects  may 
occur  in  hysteria.  Among  these  loss  of  the 
voice  with  preservation  of  whispered  speech — 
aphonia — probably  is  the  most  common.  Dif- 
ferent kinds  of  stammering  may  occur,  and 
even  the  scanning  speech  of  multiple  sclerosis 
may  be  mimicked.  In  one  rather  unusual  case 
the  patient  separated  each  word  and  each  syl- 
lable by  a  short  quick  inspiration  so  that  his 
speech  resembled  that  taught  to  patients  as  one 
of  the  features  of  a  certain  method  of  treat- 
ment of  stammering. 

Mutism  is  rare,  if  it  occurs  at  all,  in  psychas- 
thenia;  but  the  majority  of  inorganic  speech  dis- 
turbances other  than  mutism  probably  are  symp- 
tomatic of  this  psychoneurosis.     Ordinary  stam- 


Psycho-Motor  Disorders  199 

mering  and  other  spasmodic  vocal  affections  of 
like  nature  almost  invariably  are  due  to  psychas- 
thenic tics  affecting  speech,  and  their  mechanism 
differs  not  all  from  that  of  other  tics,  or  "habit 
spasms. ' ' 

Contractures.  When  a  muscle,  or  a  group 
of  muscles,  develops  a  state  of  paroxysmal 
or  constant  contraction  the  resulting  condition 
is  knov/n  as  a  contracture.  Almost  invariably 
contractures  are  the  effect  of  the  psychic  stress 
occasioned  by  some  traumatism;  severe,  trivial, 
or  supposititious.  This  symptom  is  not  frequent 
for  the  reason  that  its  causes  are  also  the  causes 
of  paralysis,  and  as  patients  possess  greater 
knowledge  of  paralysis  than  of  contractures  the 
former  are  more  apt  to  occur. 

Like  the  genesis  of  paralysis  it  is  not  the  in- 
jury itself  which  causes  the  symptom,  but  it  is 
the  idea  of  the  injury.  In  fact,  a  contracture 
may  appear  solely  as  the  result  of  belief  that 
an  injury  has  been  received  when,  in  reality, 
none  had  been  inflicted.  Florence  K.,  for  ex- 
ample, believed  that  her  finger  had  been  kicked. 
Upon  questioning  her  it  was  found  that  she  was 
not  sure  that  her  hand  actually  had  been  struck. 
Besides,  not  any  e^^dence  of  injury  could  be  dis- 
covered. Immediately  after  the  exposure  to  in- 
jury she  experienced  severe  pain,  and  the  little 
finger  became  contractured  into  the  palm.  The 
attempts  of  other  physicians  forcibly  to  reduce 
the   contracture  had  failed  because  of  the  in- 


200  PsycJiopathology  of  Hysteria 

tense  emotional  reaction  provoked  by  such  pro- 
cedures. 

On  the  third  day  my  examination  showed  that 
even  when  moderate  efforts  were  made  passively 
to  extend  the  finger  the  exaggerated  manifesta- 
tions of  pain  became  excessive,  and  the  more 
forcible  the  attempt  the  more  pronounced  be- 
came the  contraction  of  the  muscles  which  were 
responsible  for  the  condition.  The  whole  hand 
was  cold,  perspired  freely  and  presented  a  de- 
cided tremor  even  before  any  manipulation  was 
attempted.  Having  hypnotized  the  patient  the 
finger  was  straightened  without  difficulty  and 
without  causing  any  ''pain."  When  the  hyp- 
notic state  was  dispelled,  however,  the  contrac- 
ture reappeared  in  spite  of  previous  post  hyp- 
notic suggestions  which  had  as  their  end  the 
prevention  of  this  occurrence.  Accordingly,  she 
was  hypnotized  again,  the  finger  straightened, 
and  a  splint  applied.  "When  ''awakened"  she 
expressed  surprise  at  finding  her  finger  ex- 
tended. After  about  fifteen  minutes  the  splint 
was  removed  and  she  had  no  further  trouble 
either  from  pain  or  from  abnormal  muscular 
contraction. 

Contractures  may  occur  in  any  part  of  the 
body,  and,  what  indeed  is  remarkable,  even  in- 
voluntary muscles  may  be  affected.  Except  some 
of  the  contractures  produced  by  involuntary 
muscles  all  those  of  hysteria  can  be  duplicated 
by  means  of  suggestion. 


Psycho-Motor  Disorders  201 

When  originating  from  traumatism  the  loca- 
tion of  a  contracture  depends  upon  the  site  of 
injury,  and  the  pain  which  is  often  found  in 
association  either  is  entirely  psychic,  as  in  the 
case  just  mentioned,  or  it  is  an  elaboration  of 
actual  pain.  Naturally  a  patient  would  believe 
that  any  injury  which  is  severe  enough  to  re- 
sult in  a  contracture  should  be  provocative  of 
considerable  pain.  When  pain,  then,  is  present 
its  severity  is  apt  to  be  out  of  proportion  to 
the  amount  of  surgical  injury. 

The  recognition  of  hysteric  contractures  is 
usually  not  difficult.  When  the  affection  has  ex- 
isted for  a  long  time  and  when  the  associated 
symptoms  are  misleading  it  is  quite  possible, 
however,  to  attribute  the  manifestations  to  some 
organic  disease.  In  fact,  even  as  great  a 
clinician  as  Osier  speaks  of  having  repeatedly 
demonstrated  as  a  typical  example  of  lateral 
sclerosis  a  case  of  hysteric  contracture  of 
paraplegic  form.  (Practice  of  Medicine,  1902, 
p.  1114.) 

When  the  symptom  is  due  to  hysteria  the 
tendon  reflexes  are  not  disturbed  as  in  organic 
nervous  diseases,  and  the  electrical  reactions 
more  nearly  resemble  the  normal.  If  the  flexion 
or  extension  is  not  complete  examination  shows 
that  the  contraction  of  the  muscles  responsible 
for  the  condition  is  counterbalanced  by  con- 
traction of  their  opponents.  Now  suppose  we 
examine  a  case  of  flexion  of  the  forearm.  When 


202  Psychopathology  of  Hysteria 

we  attempt  forcibly  to  extend  the  forearm  the 
biceps  is  felt  to  contract  energetically  and  the 
counterbalancing  contraction  of  the  triceps 
disappears  as  onr  efforts  at  extension  render 
this  no  longer  necessary.  On  the  other  hand, 
if  we  try  to  increase  the  amount  of  flexion  of 
the  forearm  we  find  that  the  biceps  relaxes  and 
the  triceps  becomes  tense. 

If  a  whole  extremity  is  contractor ed  as  a  re- 
sult of  organic  disease  it  is  possible  to  ex- 
tend more  or  less  completely  one  part  at  a 
time,  but  the  whole  limb  cannot  be  extended  at 
the  same  time.  The  amount  of  extension  secured 
in  this  manner  is  augmented  when  the  flexion  of 
neighboring  parts  is  increased.  These  results 
cannot  be  secured  with  hysteric  contractures. 

Osseous  deformities  and  joint  changes  ordi- 
narily do  not  develop  in  long  standing  cases 
of  hysteric  contracture.  With  patients  in 
whom  the  condition  is  not  highly  organized  the 
underlying  muscular  contraction  tends  to  sub 
side  when  the  patient's  attention  is  distracted, 
and  the  contracture  may  disappear  during 
sleep,  general  anaesthesia,  the  hypnotic  state, 
and  during  somnambulistic  or  convulsive  at- 
tacks. 

The  duration  of  a  contracture  is  variable. 
Like  other  symptoms  it  has  been  known  to  per- 
sist many  years. 

In  the  treatment  of  contracture  quite  com- 
monly advantage  is  taken  of  the  relaxing  effects 


Psycho-Motor  Disorders  203 

of  etherization  in  order  to  reduce  the  deformity 
and  to  splint  the   affected  part.     Having  con- 
vinced   the    patient    that    reduction    has    been 
effected  the  contracture  does  not  tend  to  recur, 
but  it  would  be  preferable  to  leave  the  splints 
in  place  for  several  days,  or  more,  according  to 
the  duration  and  the  severity  of  the  affection. 
This  means  of  treatment  is  to  be  recommended 
only  as  a  last  resource.    Not  only  is  etherization 
disagreeable  and  not  entirely  devoid  of  danger, 
but  it  may  serve  as  the  source  of  various  other 
manifestations  of  hysteria.     Wliether  carried  to 
the  extent  of  actual  hypnosis  or  not,  suggestion 
should  be  quite  as  effectual,  and  without  any 
of  the   disadvantages   and   dangers   of   general 
anaesthesia.      In   order   to    obtain   the    greatest 
amount  of  benefit  from  suggestion  it  should  be 
reinforced — disguised — ^by    the    employment    of 
various   other    agents,   such   as   electricity   and 
massage. 

Motor  Disorders  of  the  Eye.  Among  the 
most  interesting  and  the  most  incomiprehensi- 
ble  of  the  special  types  of  contractures  and 
paralyses  are  some  of  those  occurring  in  the 
eye.  It  is  impossible,  however,  to  describe 
each  of  the  many  forms  of  ocular  disturbances 
in  a  general  work,  so  brief  mention  is  made  only 
of  a  few. 

Hysteric  contracture  of  the  orbicularis  pro- 
duces unilateral  or  bilateral  drooping  of  the  lids 
which  should  not  be  mistaken  for  organic  ptosis. 


204  PsychopatJiology  of  Bysteria 

Continual  blinking  of  the  lids,  blepharoclonus, 
is  less  frequent  in  hysteria  than  in  psychasthenia. 
Occasionally  one  meets  with  hysteric  patients 
who  seem  unable  to  displace  the  eyeballs  in  any 
direction,  but  this  apparent  ophthalmoplegia 
externa  usually  can  be  demonstrated  to  be  en- 
tirely subjective.  Frequently  the  condition  is 
apparent  only  during  examination  of  the  ocular 
muscles — it  is  suggested  upon  the  patient.  Such 
'^ paralyses"  usually  disappear  when  the  pa- 
tient's attention  is  distracted  from  the  eyes. 

Four  years  after  having  sustained  a  fracture 
of  the  skull  and  of  the  second  cervical  vertebra 
a  male  patient  developed  cerebro-spinal  menin- 
gitis. (N.  Y.  Med.  Jour.,  Dec.  5,  1908.)  During 
this  illness  there  appeared  indisputable  organic 
ophthalmoplegia  interna  and  externa  v/hich  con- 
tinued for  many  weeks  after  his  recovery.  Sub- 
sequently it  was  noticed  that  he  was  unable  to 
move  his  eyes  more  than  one-fourth  of  an  inch 
in  any  direction,  and  bilateral  ptosis  was  con- 
spicuous. That  the  former  organic  ophthalmo- 
paresis  persisted  as  a  purely  hysteric  manifesta- 
tion was  made  apparent  by  the  disappearance  of 
the  paretic  sjnuptoms  whenever  the  patient's 
attention  was  distracted. 

Conjugate  deviation  of  the  eyes  and  appar- 
ent paralysis  of  associated  ocular  muscles  are 
readily  understood,  but  it  is  difficult,  indeed, 
to  comprehend  how  hysteria  is  capable  of 
causing  paralysis  of  individual  ocular  muscles — 


Psycho-Motor  Disorders  205 

of  producing  conditions  which  one  cannot  vol- 
untarily reproduce,  or  which  cannot  be  dupli- 
cated by  hypnotic «  suggestion.  Nevertheless, 
quite  a  tew  cases  have  been  reported  in  which 
such  paralyses  have  occurred  seemingly  as 
manifestations  of  hysteria.  Onuf  satisfactorily 
accounted  for  a  case  of  hysteric  spastic  conver- 
gence and  other  ocular  symptoms  as  having 
been  due  to  the  elaboration  of  visual  symptoms 
produced  by  myopic  astigmatism.  (Jour,  of 
Abnormal  Psychol.,  vol.  2,  p.  155.)  Probably  it 
is  only  our  own  ignorance  which  prevents  us 
explaining  on  psychic  grounds  all  the  different 
hysteric  affections  of  the  ocular  muscles. 

As  cerebral  syphilis  often  causes  isolated 
ocular  palsies  that  may  not  be  associated  with 
other  obvious  evidences  of  the  disease,  and  as 
the  same  may  occur  infrequently  with  other 
organic  nervous  diseases,  one  should  exercise 
the  greatest  care  before  ascribing  these  signifi- 
cant affections  to  hysteria. 

Quite  commonly  the  pupils  are  a  little  larger 
than  usual,  and,  in  rare  cases,  pronounced 
mydriasis  with  loss  of  the  light  reflex  has  been 
noted.  Such  conditions  are  thought  to  be  due 
to  contraction  of  the  dilator  muscle  of  the  iris. 
Redlich  (Deutsche  Med.  Wochenschr.,  1908,  p. 
313,)  reported  a  case  in  which  widely  dilated 
pupils  and  loss  of  reaction  to  light  were  pres- 
ent only  during  hysteric  seizures  that  did  not 
occasion  loss  of  consciousness,  and  which  were 


206  Psychopathology  of  Hysteria 

characterized  by  crying  out,  and  muscular 
activity.  The  same  pupillary  phenomena  de- 
veloped when  the  patient  was  induced  volun- 
tarily to  reproduce  the  attacks,  provided  that 
the  muscular  contractions  were  forcible  and 
persistent.  He  believed  that  the  contraction  of 
the  muscles  of  the  neck  so  irritated  the  cervical 
sj-mpathetic  as  to  produce  mydriasis,  and  that 
in  this  case  the  condition  was  but  an  exaggera- 
tion of  the  dilatation  which  normally  occurs 
during  strong  muscular  efforts. 

During  the  attacks  of  the  case  of  hysteric 
petit  mal  reported  by  Putnam,  and  which  was 
mentioned  in  reference  to  loss  of  the  patellar 
reflexes,  the  patient  regularly  lost  the  pupillary 
light  reflex  for  several  minutes. 

Polyopia  and  monocular  diplopia  are  so  read- 
ily explained  by  the  assumption  that  the  multi- 
plication of  images  is  entirely  psychic  that  the 
involved  theory  of  unequal  refraction  of  the 
lens  due  to  ciliary  contractures  need  not  be  con- 
sidered except,  perhaps,  in  rare  instances. 
Prince's  patient  with  monocular  polyopia  saw 
such  a  large  number  of  images  that  he  had  dif- 
ficulty in  counting  them.  (Amer.  Jour,  of  the 
Med.  Sciences,  Feb.,  1897.) 

Motor  Trepidation.  During  the  examination 
of  nervous  patients  often  a  rapid  tremor  of 
small  amplitude  is  noticed  when  the  patient 
is  directed  to  hold  out  her  hands  with 
the    fingers    extended.    Such    a    tremor,    one 


Psycho-Motor  Disorders  207 

which  might  be  accurately  designated  an  at- 
tention tremor,  is  dependent  upon  the  famihar 
effects  of  conscious  attention  upon  the  per- 
formance of  an  act,  and  it  is  found  sometimes 
even  in  individuals  who  do  not  seem  to  be  ner- 
vous. More  important  are  the  slow  tremors  of 
large  amplitude  that  exist  independently  of  ex- 
amination. These  tremors  may  be  localized  or 
general,  and  they  may  appear  only  when  the 
part  is  at  rest  or  only  during  use  of  the  mem- 
ber. 

The  differentiation  of  the  intention  tremor  of 
multiple  sclerosis  from  that  which  may  occur 
as  a  symptom  of  hysteria  may  be  difficult  when 
other  manifestations  are  present  which  are 
common  to  either  disease.  Less  frequently, 
in  addition  to  rest  tremor  other  symptoms  of 
paralysis  agitans  may  be  mimicked.  Thus  a 
patient  reported  by  Gaussel  developed  by 
psychic  contagion  all  of  the  manifestations  pre- 
sented by  a  patient  with  paralysis  agitans  who 
occupied  the  next  bed.  (Gazette  des  Hopitaux, 
Nov.  7,  1908.) 

The  possible  causes  of  hysteric  tremor  are  in 
numerable.  Generally  the  different  kinds  of 
motor  agitation  are  exaggerated  but  persistent 
emotional  reactions  which  are  elaborated  from 
ones  which  were  normal.  While  committing  a 
reprehensible  act  the  arm,  for  instance,  which 
is  employed  may  tremble  as  normally  it  might 
in  consequence  of  emotional  excitement.     By 


208  Psychopathology  of  Hysteria 

autosuggestion  this  normal  trembling  may  be- 
come fixed  upon  the  patient.  When  originated 
in  this  manner  it  is  a  symbol  of  some  repulsive 
act  whose  memories,  because  of  their  unpleas- 
ant nature,  the  patient  has  voluntarily  sup- 
pressed from  consciousness. 

Another  mode  in  which  a  localized  tremor 
may  be  generated  is  that  in  which  the  patient's 
attention  is  concentrated  upon  the  activity  of 
some  one  member  while  a  general  trembling  is 
present  as  the  result  of  some  emotional  dis- 
turbance. While  shaving  a  customer  a  hysteric 
barber  became  excited,  and  the  consequent 
trembling  resulted  in  the  infliction  of  a  severe 
incision.  As  his  livelihood  depended  upon  the 
steadiness  of  his  hand  the  barber  worried  about 
his  mishap.  If  the  accident  were  repeated  he 
might  lose  his  place.  With  this  foundation  of 
expectant  attention  what  might  be  expected 
actually  appeared;  whenever  he  attempted  to 
shave  anyone,  thought  about  doing  so,  or  even 
fixed  his  attention  upon  his  hand,  decided 
tremor  developed  in  the  hand  which  he  used  in 
shaving. 

The  surgeon  often  notices  severe  trembling  of 
injured  limbs.  If  the  patient  happens  to  be  a 
hysteric  fixation  of  this  othermse  transitory 
symptom  is  almost  inevitable.  Not  infrequently 
the  irregular  movements  of  chorea  are  continued 
indefinitely  through  the  agency  of  associated 
hysteria. 


Psycho-Motor  Disorders  209 

The  effect  of  attention  upon  hysteric  tremors 
is  variable.  Distraction  of  the  patient's  atten- 
tion may  either  increase  or  decrease  the  inten- 
sity of  the  tremor,  and  concentration  of  attention 
upon  the  affected  part  may  also  have  the  same 
varying  effects.  In  psychasthenia,  however,  a 
tremor  always  is  diminished  or  caused  to  disap- 
pear during  distraction  of  the  patient's  atten- 
tion. 

Rhythmical  choreas  are  characterized  by 
rhj-thmical,  purposive,  involuntary  movements 
which  do  not  resemble  the  aimless  jerking  of 
chorea ;  neither  are  they  like  the  vibrations  of  a 
tremor.  Unlike  psychasthenic  choreiform  tics 
the  rhythmical  choreas  of  hysteria  do  not  tend 
to  disappear  during  distraction  of  the  patient's 
attention  because  the  whole  mechanism  is  sub- 
conscious. The  agitation  may  be  paroxysmal  or 
more  or  less  constant.  In  the  case  of  the  former 
each  paroxysm  is  excited  by  a  stimulus  which,  by 
association  of  ideas,  provokes  into  activity  the 
dissociated  system.  The  movements  may  origi- 
nate from  dissociated  ideas  concerning  the  occu- 
pation of  the  patient,  or  they  may  be  represen- 
tations of  some  disagreeable  experience. 

Hysteric  tremors  and  rhythmical  choreas  may 
be  looked  upon  as  rudimentary  convulsions. 
Sometimes  they  are  residues  of  former  convul- 
sive seizures.  Emma  F.,  for  instance,  had  been 
shot  in  both  arms,  and,  at  the  same  time,  she 
had  received  an  abrasion  of  the  forehead.    Imme- 


210  Psychopathology  of  Hysteria 

diately  she  became  unconscious  and  a  convulsive 
seizure  appeared — the  first  she  had  ever  experi- 
enced. Following  this  attack  she  had  others 
during  which  she  screamed  and  struggled.  After 
these  crises  had  spontaneously  disappeared  gen- 
eral trembling  and  choreiform  movements  de- 
veloped and  continued  for  seven  years.  The 
only  way  in  which  she  could  prevent  her  head 
from  participating  in  this  constant  motor  agita- 
tion was  by  means  of  holding  it  firmly  with  her 
hands.  Furthermore,  she  had  suffered  from  at- 
tacks of  what  appeared  to  be  typical  migraine 
since  she  was  injured. 

Here,  then,  is  a  case  in  which  severe  general 
trembling  originated  from  what  probably  were 
defensive  movements  of  former  somnambulistic 
attacks,  and  these  seizures,  in  turn,  represented 
her  terror  and  resistance  when  she  was  shot. 
The  original  pain  produced  by  the  abrasion  of 
her  forehead  probably  served  as  the  source  of 
her  "migraine."  The  tremor,  choreiform  move- 
ments, and  headaches  were  readily  controlled 
by  suggestion  during  a  state  of  deep  hypnosis, 
and,  after  the  third  treatment,  her  symptoms  en- 
tirely disappeared. 

The  majority  of  habit  spasm  or  tics  are  symp- 
tomatic of  psychasthenia.  The  psychasthenic 
tic  differs  from  the  rhythmical  choreas  of 
hysteria  in  that  to  a  great  extent  it  is  volun- 
tary. The  patient  is  obsessed  with  the  idea  to 
tique,   and  temporarily  to  relieve  the  mental 


Psycho-Motor  Disorders  211 

discomfort  due  to  the  impulsion  he  voluntarily 
indulges  in  the  spasmodic  muscular  contraction. 
When  his  attention  is  distracted  his  tic  is  less 
frequent  or  it  disappears,  or,  to  express  the 
condition  more  correctly,  he  does  not  have  the 
tendency  to  tique  when  his  attention  is  dis- 
tracted. 

The  imperative  ideation  which  causes  the 
psychasthenic  tic  is  disposed  to  be  most  insist- 
ent Avhen  the  spasms  are  least  desired.  When 
in  the  company  of  friends,  and  more  par- 
ticularly strangers,  the  patient,  always  em- 
barrassed and  self-conscious,  fears  that  he  will 
be  afflicted  with  his  tic,  and,  being  ashamed  of 
it,  he  apprehends  having  remarks  made  about 
his  condition.  The  consequent  state  of  ex- 
pectant attention  naturally  results  in  the  pro- 
duction, or  the  aggravation,  of  the  tic. 

The  psychasthenic  is  able  more  or  less  suc- 
cessfully to  resist  the  impulse  to  tique  until  he 
believes  himself  to  be  unobserved.  Then  he 
indulges  in  the  relief  afforded  by  a  number  of 
quickly  repeated  spasms  which  appear,  to  the 
chance  observer,  as  if  the  impulses  had  been 
accumulating,  or  as  if  the  tiquer  were  at- 
tempting to  insure  a  succeeding  interval  of 
respite  by  reason  of  excessive  indulgence.  On 
the  other  hand,  the  hysteric  is  not  embarrassed 
by  her  tic,  and,  in  fact,  she  may  not  even  be 
aware  of  the  muscular  contractions  which  are 
taking  place  independently  of  any  conscious 
impulsion. 


CHAPTER   VII 

Psycholepsy* 

THE  failure  of  the  Salpetriere  school, 
during  Charcot's  time,  to  accede  the 
contentions  of  Berheim,  to  the  effect 
that  suggestion  plays  a  most  impor- 
tant role  in  the  genesis  of  symptoms  of  hysteria, 
resulted  in  the  artificial  development,  by  them, 
of  a  type  of  convulsion  which  was  much  less 
frequently  encountered  by  other  observers  and 
which  is  rarely  seen  at  present,  unless  produced 
in  a  similar  manner,  or  unless  accidentally  and 
spontaneously  generated. 

Because  of  the  vast  amount  of  research  con- 
cerning hysteria  which  was  carried  out  by 
Charcot  and  his  followers,  and  because  of  the 
persistent  manner  in  which  their  classic  de- 
scriptions of  a  single  variety  of  hysteric  con- 
vulsion have  been,  and  are  being,  incorporated 
in  all  text  books  of  nervous  diseases,  it  is  quite 
generally  thought  that  this  particular  kind  of 
attack  is  the  only  one  which  may  be  caused  by 
hysteria.  Unfortunately,  then,  our  conception 
of  hysteric  crises  is  apt  to  be  confused  by  these 
ubiquitous  text-book  descriptions  of  manifesta- 


(*I  am  indebted  to  the  Editor  of  the  Journal  of  Ab- 
normal Psychology  for  permission  to  incorporate  in 
this  section  material  drawn  from  a  previous  paper 
entitled  "Psychogenetic  Convulsions"  Jour,  of  Abn. 
Psych.,   vol.   5,   p,   1.) 

212 


Psycholepsy  213 

tions  which  were  purely  the  result  of  most 
elaborate,  but  unconscious,  suggestion  and  of 
psychic  contagion,  and  which  occurred  almost 
exclusively  in  a  comparatively  small  group  of 
patients  in  one  hospital.  Indeed,  the  majority 
of  text-book  considerations  of  the  disease  do- 
not  show  that  there  has  been  any  progress  in 
our  knowledge  of  this  disease  since  the  time  of 
Charcot.  This  affects  more  particularly  those 
who  do  not  specialize  in  neurology  and  who  are 
dependent,  therefore,  upon  text-books.  Conse- 
quently, these  practitioners  are  led  to  infer  that 
hysterics  are  capable  of  presenting  only  one 
kind  of  attack — hystero-epilepsy,  grande  hy- 
steric, hysteria  major — and  as  the  effect  of  their 
inference  other  varieties  are  most  apt  to  be 
looked  upon  as  being  epileptic  in  origin. 

The  attack  of  grande  hysteric  was  divided  into 
five  stages:  (1)  The  prodromal  stage.  (2) 
The  epileptoid  stage.  (3)  The  period  of 
clowmism,  or  of  movements  of  wide  range.  (4) 
The  period  of  emotional  attitudes.  (5)  The 
period  of  delirium.  The  following  is  a  sum- 
mary of  descriptions  of  the  whole  attack  as 
elaborated  by  Charcot,  Richer,  and  others  of 
the  Salpetriere  school: 

1.  The  prodromal  stage  is  characterized  by 
various  mental  disturbances  which  may  continue 
even  for  days,  or  for  weeks,  before  the  onset  of 
the  actual  seizure.  Objectively,  the  patient's 
actions  de^date  markedly  from  her  usual  stan- 


214  FsychopatJiology  of  Hysteria 

dard;  mainly  because  she  becomes  unusually 
emotional  and  irritable.  Subjectively,  she  may 
experience  almost  any  kind  of  sensory  or  psychic 
disturbances.  The  premonitory  stage  terminates 
with  an  aura  which  usually  consists  of  globus 
hystericus,  dimness  of  vision,  tinnitus,  etc.  Fol- 
lowing the  aura  the  patient  cries  out,  falls  care- 
fully to  the  ground,  and  loses  consciousness. 

2.  The  epileptoid  stage.  This  stage  consists 
of  a  period  of  tonic  rigidity  followed  by  clonic 
convulsions  and  concluding  with  muscular  re- 
laxation and  stupor;  the  whole  lasting  but  a 
few  minutes. 

3.  The  period  of  clownism  then  appears.  The 
patient's  body  is  tossed  about  wildly  by  reason 
of  forcible  muscular  contractions — of  movements 
of  wide  range — and,  most  characteristically,  the 
highest  degree  of  opisthotonos  develops.  Towards 
the  close  of  this  period  she  exhibits  manifesta- 
tions of  great  fear,  or  of  rage.  Tearing  her 
clothes  and  biting  at  those  who  are  trying  to 
hold  her  she  acts  more  like  a  wild  animal  than 
a  human  being. 

4.  The  period  of  emotional  attitudes  gradu- 
ally develops  from  that  of  clownism  after  the 
latter  has  lasted  a  short  time.  The  attitudes  are 
the  dramatic  representation  of  various  emotions 
aroused  by  the  hallucinations  which  the  patient 
is  experiencing,  and  whose  character  is  depend- 
ent upon  the  nature  of  the  primary  exciting 
cause.    In  fact,  the  postures  and  the  type  of  the 


Psycholepsy  215 

subsequent  delirium  are  indices  of  the  patient's 
ideas  at  the  time.  Consequently,  they  signify 
the  original  cause  of  the  condition. 

5.  The  period  of  delirium  is  a  continuation 
of  the  stage  of  emotional  attitudes  from  which 
it  differs  only  in  that  with  the  gradual  return  of 
consciousness  the  patient  gives  verbal  expression 
to  her  hallucinations,  and  the  posturing  disap- 
pears. 

The  entire  attack  may  last  from  fifteen  min- 
utes to  an  hour,  but,  in  some  cases,  the  pro- 
longation of  certain  stages,  or  the  occurrence  of 
repetitions  of  some  of  the  stages,  or  of  the  whole 
<jrisis,  may  cause  the  condition  to  persist  for 
many  hours,  and  even  for  several  days.  Such 
an  extended  seizure,  or  succession  of  seizures, 
then  constitutes  status  hystericus. 

The  objection  to  the  elaborate  and  arbitrary 

descriptions  of  w^hat  is  called  grande  hysteric 

an  attack  which  was  asserted  to  be  character- 
istic of  severe  hysteria— is  that  when  we  dis- 
regard the  effects  of  clinical  education  and  of 
psychic  contagion  one  never  encounters  a  pa- 
tient whose  seizures  include  all,  or  even  most 
of  these  stages ;  the  reason  for  this  being  that 
the  so-called  hystero-epileptic  attack  represents 
a  composite  of  a  number  of  the  common  varie- 
ties of  hysteric   crises. 

It  is  significant,  indeed,  that  of  the  large 
number  of  cases  of  hysteria  that  Janet  was 
the  first  to  study  only  two  patients  presented 


216  PsychopatJiology  of  Hysteria 

crises  which  conformed  to  the  classic  descrip- 
tions of  grande  hysteric.  The  same  author 
brought  together  in  the  same  ward  three 
hysterics  who  separately  presented  three  dif- 
ferent kinds  of  seizures.  ''I  was  quite  sur- 
prised," he  remarks,  ''to  see  that  after  some 
time  their  symptoms  were  intermingled  and 
that  they  had  all  three  the  same  crises,  with 
the  same  movements,  the  same  delirium,  the 
same  invectives  against  the  same  individual. 
Little  was  wanting  for  a  new  type  of  hysteria 
to  be  formed  in  that  ward  which  later  might 
have  been  studied  as  natural."  (Mental  State 
of  Hystericals,  399  and  406.) 

Grande  hysteric  is  similar  to  le  grande  hyp- 
notisme  in  that  the  "stages"  of  each  are  artificial 
products — clinical  artefacts  originating  in  sug- 
gestion and  psychic  contagion.  It  is  impossible 
to  divide  hypnotism  and  the  innumerable  kinds 
of  hysteric  crises  into  stages,  for  no  two  patients 
are  alike  in  their  hypnotic  and  hysteric  reactions, 
and  the  nature  of  either  of  these  conditions  de- 
pends largely  upon  that  widely  varying  factor^ 
the  individual  psychic  equation. 

To  satisfy  that  universal  scientific  desire  for 
classification  of  objects  and  phenomena  that  often 
are  incapable  of  being  satisfactorily  classified, 
we  may  attempt  to  divide  the  many  types  of 
hysteric  crises  themselves  into  what  at  best  can 
be  only  arbitrary  and  unstable  groups.  Then, 
if  the  classification  is  sufficiently  comprehen- 


Psycholepsy  217 

sive,  we  have  what  is  merely  a  clinically  useful 
means  of  grouping  our  cases,  or  of  signifying 
in  a  few  words  the  main  features  of  the  attacks 
of  some  case  of  hysteria.  Therefore,  the  follow- 
ing incomplete  classification  may  be  conven- 
ient : — 


Attacks  Characterized  Mainly  by  Motor 
Agitation  in  Addition  to  an  Altered  State 
OF  Consciousness. 

1.  Psycholepsy. 

A.  Major  epileptiform  convulsions. 

B.  Focal  epileptiform  convulsions. 

2.  Emotional  crises. 


Ambulatory    Seizures    with    an    Altered 
State  of  Consciousness. 

1.  Nocturnal  somnambulism. 

2.  Fugues  and  ambulatory  automatism. 

Attacks  whose  Main   Feature  is  an  Al- 
tered State  of  Consciousness. 

1.  Syncopal  attacks. 

2.  Petit  mal  seizures. 

3.  Narcolepsy. 

4.  Catalepsy. 

5.  Trance  states. 

6.  Ecstacy. 


218  Psychopathology  of  Hysteria 

After  making  a  careful  analysis  of  the  his- 
tories of  100  consecutive  cases  of  hysteria  it 
was  found  that  62%  had  presented  one  or  more 
kinds  of  hysteric  seizures.  This  percentage 
closely  approaches  that  of  Pitres,  namely,  63%. 
Recording  only  the  most  severe  form  of  attack 
of  each  patient  it  was  found  that  in  the  hun- 
dred histories  examined  the  incidence  was  as 
follows :  Major  epileptiform  seizures,  24% ; 
focal  epileptiform  attacks,  4% ;  pseudo  petit 
mal,  4%  ;  ambulatory  automatism  and  fugues — 
''psychic  epilepsy" —  3%;  narcolepsy,  4%; 
various  kinds  of  simple  emotional  crises,  8%  : 
syncopal  attacks,  15%.  Of  the  major  epilepti- 
form variety  of  hysteric  seizure  there  were 
more  than  five  patients  whose  crises  were  iden- 
tical with  those  of  epilepsy,  and  the  proper 
diagnosis  of  these  patients  depended  entirely 
upon  the  results  of  psychoanalysis*  and  upon 
"cure"  by  psychotherapy  without  the  use  of 
bromides.  At  least  two  of  the  cases  of  focal 
epileptiform  attacks  had  been  diagnosed  by 
more  than  one  physician  as  due  to  organic  brain 
disease.  Not  a  single  patient  presented  seizures 
which  even  approached  the  descriptions  of 
hystero-epilepsy,  but  quite  a  few  instances  were 
recorded  of  attacks  which  resembled  more  or 
less  atypically  a  single  stage,  or  a  combination 
of  several  stages,  of  grande  hysteric. 

r*i  *In  this  work  the  term  psychoanalysis    is    employed 

comprehensively  to  desig-nate  any  researches,  reg-ard- 
less  of  techniqvie,  having  as  their  end  the  discovery  of 
causes  of  psychopathic  conditions. 


Psycholepsy  219 

In  describing  the  seizures  of  hysteria  the  se- 
quence which  will  be  observed  is  neither  in 
accordance  with  the  above  outline  nor  is  it  one 
which  is  logical;  like  the  classification  it  is 
merely  convenient. 

The  emotional  crises  of  hysteria  vary  in  char- 
acter and  in  severity  from  simple  attacks  of 
''hysterics"  and  of  sjmcope  to  seizures  which 
resemble  one  or  more  of  the  periods  of  clown- 
ism,  emotional  attitudes,  and  delirium  of  the  old 
hystero-epilepsy.  The  mild  types  are  charac- 
terized by  an  emotional  display  of  uncontrol- 
able  laughing  and  crying.  When  the  attack 
results  from  anger  the  patient  may  destroy 
objects  which  happen  to  come  under  her  obser- 
vation. Ordinarily,  such  crises  are  looked  upon 
as  reprehensible  outbursts  of  temper.  When 
more  severe  the  seizure  is  accompanied  by  a 
clouded  state  of  consciousness  with  subsequent 
partial  or  complete  amnesia  for  the  period  of 
the  attack. 

The  different  emotional  crises  may  be  divided 
into  separate  stages  which  vary  entirely  accord- 
ing to  the  individual.  One  patient  may  suddenly 
become  unconscious,  exhibit  some  grand  move- 
ments with  resistance,  and  then  recover  con- 
sciousness mthout  manifesting  any  other  phe- 
nomena. Another  one  partially  loses  conscious- 
ness, and,  after  a  period  of  grand  movements 
or  passional  attitudes,  passes  into  what  appears 
to  be  a  state  of  stupor.    After  recovering  from 


220  Psychopathology  of  Hysteria 

the  attack  this  patient  informs  ns  that  while 
lying  motionless  and  apparently  unconscious  she 
heard  everything  that  was  said,  but  she  could 
neither  talk  nor  move.  A  third  ordinary  type 
of  seizure  consists  in  a  somnambulistic  state  dur- 
ing which  the  patient  hallucinates  some  former 
episode — usually  the  one  which  acted  as  the  ex- 
citing cause  of  her  disease — and  repeats  more 
or  less  accurately  and  intelligibly  her  original 
reactions.  One  of  the  most  common  kinds  of 
simple  emotional  attacks  is  characterized  by  an 
aura,  followed  by  a  cry,  and  loss  of  conscious- 
ness. The  patient  falls  more  or  less  carefully 
to  the  floor,  undergoes  a  period  of  epileptoid 
movements,  struggles  wildly  with  those  who  are 
aggravating  matters  by  trjdng  to  prevent  her 
from  hurting  herself,  and  then  recovers  con- 
sciousness, usually  without  presenting  any  sub- 
sequent stupor. 

The  recognition  of  the  many  possible  kinds 
of  elementary  emotional  crises  is  without  diffi- 
culty. With  ordinary  care  in  obtaining  a  his- 
tory and  in  making  the  physical  examination  it 
should  be  impossible  to  make  any  mistake  in 
the  diagnosis.  The  causes,  psychic  mechanism, 
and  treatment  of  these  attacks  is  the  same  as 
that  of  the  more  grave  types  of  epileptiform  con- 
vulsions, and,  consequently,  these  features  will 
receive  collective  attention  at  the  close  of  this 
chapter. 

In  common  with  other  diseases  whose  nature 


Psycholepsy  221 

has  been  but  illy  understood  and  which  have 
served  as  resources  of  diagnostic  convenience,  if 
not  ignorance,  epilepsy  is  being  diagnosed  less 
frequently  as  our  knowledge  of  this  disease  pro- 
gresses, but  more  particularly  so  as  the  result  of 
our  recognition  of  the  fact  that  epileptiform 
manifestations  may  occur  in  diseases  other  than 
epilepsy,  and  especially  is  this  true  of  the  func- 
tional neuroses.  On  the  other  hand,  hysteria  and 
psycliasthenia  are  the  two  diseases  the  diagnosis 
of  which  has  increased  most  in  frequency  at  the 
expense  of  that  of  epilepsy.  Uncomplicated 
neurasthenia,  however,  probably  never  causes 
«on\Tilsions. 

It  is  conceded  now  that  the  psychoneuroses 
<3an  mimic  very  closely  the  different  kinds  of 
■epileptiform  attacks.  Indeed,  not  a  few  cases  of 
con^oilsions  of  psychopathic  origin  have  been  re- 
garded as  typical  examples  of  major  epilepsy, 
and  mistakes  are  even  more  frequent  in  the 
diagnosis  of  petit  mal  and  "psychic  epilepsy." 

Some  of  those  who  have  made  psychoanalytic 
researches  of  epilepsy  and  psycholepsy  believe 
that  a  not  inconsiderable  number  of  cases  of  sup- 
posed major  epilepsy,  many  cases  of  petit  mal, 
and  all  cases  which  were  formerly  considered  to  be 
psychic  epilepsy,  in  reality  are  not  epilepsy,  but 
are  manifestations  of  those  psychoneuroses  which 
clinically  are  known  as  hysteria  and  psychas- 
thenia.  George  M.  Parker,  for  instance,  is  radical 
enough  to  state  that  "what  is  often  regarded 


222  Psychopathology  of  Hysteria 

as  epilepsy  does  not  really  belong  there, — that 
many  a  '  typical '  epilepsy  may  on  a  closer  study 
turn  out  to  be  a  functional  psychosis.  This 
is  especially  true  of  the  so-called  'psychic 
epilepsies/  which,  as  the  psychopathological 
researches  of  our  laboratory  on  many  other 
different  cases  incontestably  demonstrate,  are 
all  pure  functional  psychoses,  subconscious  dis- 
sociated states,  having  the  tendency  to  recur, 
periodically  or  not,  with  all  the  energy  charac- 
teristic of  a  fully  dissociated  system,  reproduc- 
ing the  original  psychomotor  conditions  dur- 
ing the  accident,  and  often  closely  mimicking 
the  psychomotor  manifestations  of  epilepsy." 
(Psychopathological  Researches  in  Mental  Dis- 
sociation, by  Boris  Sidis,  1908.) 

In  speaking  of  the  term  psychic  epilepsy,  Sidis 
writes :  ' '  This  term,  though  ambiguous,  may  be 
accepted,  if  understood  not  in  the  sense  of  epil- 
eptic origin  or,  as  it  is  put,  'psychic  equivalent' 
of  epilepsy,  but  as  epileptoid  disturbances  of  a 
purely  mental  character  due  to  dissociative 
states  of  functional  neuropsychosis ;  in  the  same 
way  as,  for  instance,  psychic  anassthesias  of 
functional  diseases  are  not  equivalents  of  organic 
neuron  degenerations."  ^^The  phenomena  of 
^psychic'  epilepsy  are  of  the  nature  of  post- 
hypnotic automatisms.'*     (Ibid.) 

Since  it  has  been  recognized,  in  the  last  few 
years,  that,  in  addition  to  hysteria,  psychas- 
thenia  also  may  occasion  epileptiform  seizures 


PsycJiolepsy  223 

the  differential  diagnosis  has  become  even 
more  difficult.  It  cannot  be  emphasized  too 
strongly  that  the  diagnosis  epilepsy  is  justi- 
fiable only  when  all  other  diseases  which  are 
capable  of  inducing  epileptiform  attacks,  par- 
ticularly hysteria  and  psychasthenia,  either 
positively  can  be  excluded  or  recognized  as 
associated  conditions.  For  it  is  quite  common 
to  encounter  patients  in  v^hom  hysteria  or 
psychasthenia  have  been  superimposed  upon  an 
epileptic  foundation  just  as  multiple  sclerosis 
usually  is  complicated  with  hysteria. 

Because  an  attack  per  se  may  possess  all  the 
features  of  one  due  to  epilepsy  is  no  reason 
why  the  patient  should  be  considered  as  epi- 
leptic. It  is  granted  now  that  hysterics  and 
psychasthenics  not  only  may  have  auras  which 
may  be  similar  to  those  of  epilepsy,  but  that 
during  crises  they  not  infrequently  injure 
themselves  in  falling,  have  involuntary  evacua- 
tions of  the  bladder  and  rectum,  and  bite  their 
tongues.  The  presence  or  absence,  therefore, 
of  these  accidents  no  longer  can  be  regarded 
as  differential  characteristics.  ."It  is  becoming 
recognized,"  observes  Ernest  Jones,  ''that  in  a 
grand  mal  attack  there  may  be  absolutely 
nothing  in  the  nature  of  the  attack  itself  to  in- 
dicate its  source."  (Mechanism  of  a  Severe 
Briquet  Attack,  Jour,  of  Abnormal  Psych. ^ 
vol.  2,  p.  219.) 


224  Psychopathology  of  Hysteria 

As  the  psychoneuroses  are  only  closely 
inter-related  clinical  syndromes  which  very 
frequently  are  indistinguishable  from  one  an- 
other it  is  always  difficult,  and  often  impos- 
sible, to  differentiate  the  attacks  which  may 
occur  as  symptoms  of  these  conditions.  For 
this  reason  it  is  often  convenient  to  include  the 
psychogenetic  crises  either  of  hysteria  or  of 
psychasthenia  under  the  designation  psychol- 
epsy. 

Formerly  the  French  writers  applied  the 
term  hystero-epilepsy  to  hysteria  when  this  dis- 
ease occasioned  what  might  be  called  the 
Salpetriere  type  of  convulsion — grande  hysterie. 
Unfortunately,  the  significance  of  this  name  has 
been  degraded  by  the  indiscriminate  manner 
in  which  it  is  used  at  present.  Beside  its 
original  connotation  it  is  used  by  various 
writers  to  signify  the  coexistence  of  hysteria 
and  epilepsy,  and  some  have  attempted  even  to 
distinguish  a  new  disease,  to  which  they  apply 
this  name,  which  is  neither  hysteria  nor 
epilepsy.  As  the  term  is  no  longer  distinctive 
it  should  be  discarded  from  modern  neurologic 
nomenclature.  The  designations  hysteric  con- 
vulsions and  psychasthenic  convulsions  are 
ones  which  cannot  be  confounded  with  epilepsy, 
or  otherwise  misinterpreted,  while  the  term 
Briquet  attack  is  useful  to  signify  the  many 
atypical  and  less  completely  developed  forms 
of  hysteric  and  psychasthenic  emotional  crises. 


Psycholepsy  225 

It  is  safe  to  say  that  there  is  no  type  of 
seizure  which  is  characteristic  either  of  hysteria 
or  of  psj^chasthenia,  and  that  because  of  the 
psychic  mode  of  genesis  of  manifestations  of 
these  diseases  any  kind  of  attack  is  possible. 
However,  in  these  psychoneuroses  it  is  prob- 
able that,  with  the  exception  of  simple  emo- 
tional crises,  major  epileptiform  convulsions 
occur  more  frequently  than  any  other  variety 
of  seizure.  There  are  two  good  reasons  for 
the  preponderance  of  this  type  of  convulsive 
syndrome :  quite  commonly  psychic  contagion 
leads  to  the  development  of  heterogenous 
psycholepsy,  and,  secondly,  the  malady  origin- 
ates less  frequently  autogenically  as  the  direct 
elaboration  of  normal  psychic  reactions  to  in- 
tense emotion. 

It  is  not  at  all  unusual  for  normal  persons  to 
have  witnessed,  or  to  have  read  descriptions  of, 
an  epileptic  crisis,  and  it  is  to  be  deplored  that 
cases  of  psychoneurosis  have  far  greater  oppor- 
tunity of  acquiring  information  concerning  the 
features  of  such  attacks  owing  to  the  fact  that 
in  hospital  practice  these  unfortunates  are  usually 
treated  in  the  same  wards  with  epileptics. 

Psycholepsy  may  develop  while  the  patient  is 
exposed  to  psychic  contagion,  or  the  knowledge 
which  she  has  acquired  of  convulsions  may  re- 
main dormant  until  some  exciting  cause  precipi- 
tates the  kind  of  attack  with  which  she  is 
familiar,  and  which  she  may  have  feared  and 
expected. 


226  PsycJiopathology  of  Hysteria 

If  we  subject  all  of  our  cases  of  psycholepsy 
to  a  searching  inquiry  we  will  find  that  from 
50  to  75%  of  the  patients  have  been  more  or 
less  closely  associated  with  epileptics.  Also, 
that  frequently  they  have  observed  epileptic 
convulsions  and  that  their  seizures  are  identical 
with  those  which  they  have  witnessed.  In 
many  of  these  cases  we  can  trace  the  patient's 
attacks  so  directly  to  ones  which  were  observed 
during  exciting  circumstances  in  friends  or 
relatives  that  their  genesis  by  psychic  con- 
tagion is  indubitable.  Mention  has  already 
been  made  of  the  son  who  developed  hysteric 
Jacksonian  seizures  whose  features  were  pre- 
cisely like  those  of  his  hysteric  mother.  In 
another  interesting  case,  one  of  major  epilepti- 
form convulsions  due  to  hysteria,  the  seizures 
developed  after  the  patient  had  seen  her  infant 
brother  undergo  a  large  number  of  convulsions 
during  the  course  of  a  fatal  attack  of  pertussis. 
Though  many  similar  instances  might  be  cited 
from  personal  experience  one  abbreviated 
record  is  sufficient  to  illustrate  the  influence 
of  psychic  contagion,  reinforced,  in  this  ease, 
by  direct  hetero-suggestion. 

Elizabeth  M.,  a  mill-girl,  aet.  22,  had  never 
experienced  any  seizures  until  July  29,  1907, 
when  suddenly,  and  without  afterwards  being 
consciously  aware  of  any  apparent  cause,  she 
screamed,  ran  a  few  steps,  and  then  fell  un- 
conscious.     General   tonic   and   clonic    spasms 


Psycholepsy  227 

appeared,  of  which  the  movements  of  her  jaw 
caused  a  laceration    of    the  tongue.     After    a 
postconvulsive  stuporous    state    which    lasted 
three  hours  she  regained  consciousness,  but  felt 
exhausted.     Upon  the  advice  of  her  physician 
she  remained  in  bed  three  days.    During  two 
nocturnal  major  convulsions  evacuations  of  the 
bladder  occurred.    Besides  this  type  of  attack 
she  had  numerous  emotional  ones  which  were 
preceded  by  a  peculiar  sensation  originating  in 
the  epigastric  region  and  which  caused  her  to 
feel   faint.     The   subjective   sensations   of  the 
attack  itself  consisted  of  palpitation,  dyspnoea, 
and  exhaustion. 

The  patient  was  unaware  of  the  causes  of  any 
of  her  manifestations.  She  knew,  however, 
without  appreciating  its  genetic  significance, 
that  each  diurnal  attack  was  preceded  by  fear 
and  expectant  attention.  Often  she  would  say 
to  her  mother:  "I  know  that  I  am  going  to 
have  an  attack  to-night."  Frequently  she  had 
nocturnal  seizures  which  were  succeeded  by 
localized  amnesia,  and  which  were  characterized 
by  calling  for  her  parents,  irrational  talk,  and 
apparent  fear. 

The  statements  of  the  mother,  and  the  results 
of  interrogation  of  the  patient  before  and  dur- 
ing hypnosis,  indicate  that  the  mechanism  of 
genesis  of  her  sjTnptoms  was  as  follows:  Until 
she  was  15  years  of  age  she  had  never  exhibited 
any     manifestations     of    nervousness;    always 


228  Psycliopathology  of  Hysteria 

having  been  socially  inclined  and  full  of  fun. 
Her  menses  did  not  appear  until  her  twentieth 
year,  and  following  their  establishment  she 
menstruated  only  every  three  months.  Because 
her  menstrual  function  was  not  like  that  of 
other  girls  she  worried  excessively  about  her 
health.  Indeed,  she  thought  that  she  had  an 
abdominal  tumor  and  that  surely  she  would 
die  soon.  The  girls  with  whom  she  associated 
encouraged  her  belief  in  the  serious  import  at 
first  of  her  failure  to  menstruate,  and  later,  of 
the  abnormal  periodicity  of  this  function. 

Now,  six  months  before  her  first  seizure,  and 
in  her  presence,  a  friend  was  seized  with  a 
convulsion.  ■  The  shock  of  the  incident  was  in- 
creased and  rendered  more  personal  by  the 
fact  that  this  friend  subsequently  told  her  that 
she  was  subject  to  convulsions  because  of 
menstrual  irregularities,  and,  furthermore,  that 
these  abnormalities  were  the  same  as  Eliza- 
beth's, therefore  Elizabeth  surely  would  de- 
velop convulsions.  Following  this  accident  and 
the  suggestive  explanation  of  its  cause  Eliza- 
beth worried  much  about  the  possibility  of  the 
same  condition  appearing  in  herself.  Fre- 
quently she  asserted  that  she  would  become  an 
epileptic,  and  her  mother  stated  that  she  talked 
constantly  about  this  disease.  Finally  the  in- 
evitable took  place ;  she  began  to  have  con- 
vulsions which  at  first  were  exactly  like  the 
one  she  had  witnessed. 


Psycholepsy  229 

In  September,  1908,  she  became  engaged  to 
a  man  who,  four  months  after  having  impreg- 
nated her,  jilted  her  following  a  quarrel.  Hav- 
ing taken  the  matter  to  court  and  thus  secured 
unenviable  newspaper  notoriety  she  was  ostra- 
cised by  her  friends.  Naturally,  these  unfortu- 
nate occurrences  greatly  aggravated  her  nervous 
condition,  and  she  became  obsessed  with  the 
idea  of  killing  her  violator,  regardless  of  the 
consequences. 

The  type  of  attack  which  simulated  petit  mal 
developed  only  after  the  quarrel.  Each  of  these 
crises  was  caused  either  by  thinking  about  her 
troubles,  by  worrying  over  the  fact  that  she  was 
pregnant,  or,  subsequently,  by  reproaching  her- 
self for  having  provoked  an  abortion  by  means  of 
drugs.  The  nocturnal  attacks  were  induced  by 
thinking  of  her  lover  before  retiring,  or  by  erotic 
dreams  of  which  he  was  the  subject.  A  number 
of  psychasthenic  obsessions  with  which  she  was 
afflicted  were  traced  in  the  same  manner  to 
the  nervous  shocks  which  she  had  sustained. 

These  results  of  analysis,  though  apparently 
so  simple  and  so  easily  ascertained,  could  have 
been  obtained  only  by  means  of  some  psycho- 
analytic method — ^hypnotism  in  this  case — for 
the  reason  not  only  that  -  she  was  not  con- 
sciously aware  of  the  causal  relations  between 
her  various  manifestations  and  the  psychic 
stresses,  but  that  some  of  these  had  been  en- 
tirely forgotten,  or  suppressed.     Without  such 


230  Psychopathology  of  Hysteria 

painstaking  research  she  would  have  been  con- 
sidered an  epileptic  and  treated  unavailingly 
as  such. 

The  diagnosis,  psychasthenic  convulsions,  was 
suggested  by  the  presence  of  other  indubi- 
table evidences  of  psychasthenia.  It  was  jus- 
tified by  the  discovery  of  an  adequate  and 
direct  emotional  cause,  by  the  successful  re- 
production, through  the  agency  of  hypnosis,  of 
memories  of  events  which  occurred  during  at- 
tacks; and  by  reproduction  of  memories  of  a 
subconscious  cause  for  individual  seizures. 

During  a  period  of  two  months  the  patient 
was  treated  nine  times  with  hypnotic  sugges- 
tion. After  the  second  treatment  her  obsessions 
disappeared  and  major  convulsions  no  longer 
recurred.  Attacks  of  pavor  nocturnus  con- 
tinued to  occur  much  less  frequently  as  the  con- 
sequence of  dreaming  about  her  former  lover, 
and  each  dream  was  found  to  have  been  pre- 
ceded during  the  day  by  conversations  about 
this  man.  Unfortunately,  the  patient  discon- 
tinued treatment  before  further  improvement 
could  be  obtained.  As  she  had  responded  so 
well  to  psychotherapy  probably  all  of  her 
neurotic  manifestations  could  have  been  caused 
to  disappear  had  she  continued  the  treatment  a 
little  longer.  A  most  detrimental  factor  in  the 
case  was  the  fact  of  her  constantly  being  re- 
minded of  her  troubles;  her  father  and  many 
of  her  friends  refusing  to  speak  to  her  on  ac- 


Psycholepsy  231 

<30unt  of  her  fall  from  virtue,  and  because  the 
law  suit  had  not  been  terminated. 

The  influence  of  contagion  in  the  genesis  of 
psychogenetic  convulsions  is  shown  even  more 
forcibly  in  epidemic  hysteria  than  in  indi- 
vidual cases  of  the  disease.  Take,  for  instance, 
the  epidemic  of  hysteria  which  reigned  among 
the  American  Indians  during  the  height  of  the 
ghost  dance  epoch.  At  a  dance  held  on  White- 
€lay  Creek  100  out  of  3,000—4,000  Indians 
succumbed  to  syncopal,  convulsive,  ecstatic,  or 
other  seizures.  (Fourteenth  Annual  Report  of 
the  Bureau  of  Ethnology  to  the  Sec.  of  the 
Smithsonian  Institution,  part  2,  p.  917.)  Or. 
^mong  civilized  whites,  about  3,000  persons,  or 
one  in  every  six  of  those  exposed,  fell  to  the 
ground  with  similar  crises  during  one  of  the 
early  Kentucky  revivals.  (Citation  by  Daven- 
port, Primitive  Traits  in  Religious  Revivals, 
1906,  p.  77.) 

Now  let  us  investigate  the  sources  of  auto- 
genous psycholepsy.  It  is  well  known  that  any 
•emotion  tends  to  produce  physical  expression 
and  that  if  the  emotional  perturbation  be 
sufficiently  intense  diffuse  muscular  activity  is 
inevitable.  As  the  normal  reaction  to  any 
severe  mental  stress,  general  tremors,  convul- 
sive movements,  dilated  pupils,  and  flushing,  or 
pallor,  develop  with  their  associated  emotional 
states  of  fear,  anger,  etc.,  according  to  the 
nature  of  the  exciting  cause  and  according  to 


232  Psychopathology  of  Hysteria 

the  individual.  If  the  emotional  disturbance 
be  sufficiently  pronounced  then  syncope  may  be 
a  terminal  phenomenon. 

When  occurring  in  psychopaths  these  normal 
reactions  may  become  elaborated  subcon- 
sciously, by  reason  of  the  diminution  of 
cerebral  inhibition  which  is  characteristic  of 
these  patients,  and  they  may  then  occur,  in  this, 
elaborated  manner,  without  being  consequent 
upon  what  normally  would  be  an  adequate  ex- 
ternal exciting  cause  ;  recurrence  being  effected 
by  pathologic  association  of  ideas.  These 
anomalous,  or  perverted,  and  elaborated  reac- 
tions then  constitute  psycholeptic  attacks.  Ac- 
cording to  this  manner  of  genesis  convulsions, 
if  present,  are  merely  the  result  of  elaboration 
of  the  motor  agitation  which  is  a  constituent 
of  a  normal  emotional  reaction,  and  the  accom- 
panying loss  of  consciousness  is  a  temporarily 
massive^  dissociation  which  is  evolved  from  the 
syncope. 

It  does  not  require  any  stretch  of  the  imagin- 
ation to  conceive  how  one  who  is  afflicted  with 
a  disease  whose  main  objective  characteristic 
is  increased  emotivity  can  develop  psycholepsy 
from  what  normally  would  be  a  minor  psychic 
stress.  If  we  study  the  normal  reactions  ta 
excessive  emotional  states  we  find,  in  fact,  that 
they  very  closely  resemble  epileptic  convul- 
sions. In  describing  the  physical  expression  of 
fear  Darwin  (The  Expression  of  the  Emotions. 


Psycholepsy  233 

in  Man  and  Animals,  173,  p.  291,)  wrote:  "As 
fear  increases  into  an  agony  of  terror,  we  be- 
hold, as  under  all  violent  emotions,  diversified 
results.  The  heart  beats  wildly,  or  may  fail  to 
act  and  faintness  ensue;  there  is  a  death-like 
pallor;  the  breathing  is  laboured;  the  wings  of 
the  nostrils  are  widely  dilated;  .  .  .  ." 
''The  pupils  are  said  to  be  enormously  dilated. 
All  the  muscles  of  the  body  may  become  rigid, 
or  may  be  thrown  into  convulsive  movements. 
The  hands  are  alternately  clenched  and  opened, 
often  with  a  twitching  movement.  The  arms 
may  be  protruded,  as  if  to  avert  some  dreadful 
danger,  or  may  be  thrown  wildly  over  the 
head."  Concerning  the  reactions  to  pain  the 
same  author  stated  (Ibid.  p.  70.)  :  "With  man 
the  eyes  stare  wildly  as  in  horrified  astonish- 
ment, or  the  brows  are  heavily  contracted. 
Perspiration  bathes  the  body,  and  drops  trickle 
down  the  face.  The  circulation  and  respiration 
are  much  affected.  Hence  the  nostrils  are 
generally  dilated  and  often  quiver;  or  the 
breath  may  be  held  until  the  blood  stagnates  in 
the  purple  face.  If  the  agony  be  severe  and 
prolonged,  the  signs  all  change ;  utter  prostra- 
tion follows,  with  fainting  or  convulsions." 

These  descriptions  might  be  applied  with 
just  as  much  accuracy  to  many  of  the  attacks 
of  hysteria,  for  are  not  these  crises  only  the 
exaggeration  of  normal  reactions?  The  hys- 
teric  emotional  reaction   is   abnormal  only  in 


234  Psycho  pathology  of  Hysteria 

that  it  occurs  in  the  absence  of  what  normally 
would  be  considered  a  commensurate  external 
stimulus.  Like  many  other  symptoms  of  the 
disease  the  exaggeration  of  reactions  represents 
reversion  to  juvenile  types  of  reaction.  On  ac- 
count of  the  psychic  instability  of  children 
moderate  pain  and  emotional  disturbances,  in- 
stead of  being  expressed  by  local  convulsive 
movements  of  the  face,  and  by  other  lesser 
modes  of  externalization,  arouse  a  more  pro- 
found reaction,  so  that  syncope  and  convulsions 
may  be  provoked. 

Granting  that  psychic  contagion  was  re- 
sponsible for  the  majority  of  convulsive  attacks 
which  occurred  so  universally  during  ghost 
dances,  Kentucky  revivals,  early  Methodism, 
and  in  many  other  religions,  victims  were  re- 
quired to  initiate  the  contagion.  Certainly  all 
of  these  could  not  have  been  individuals  who 
had  been  previously  subject  to  the  malady. 
The  convulsions  of  many  of  these  originators 
of  contagion  undoubtedly  represented  simply 
th6  tendency  of  extreme  mental  excitement  to 
be  propagated  as  muscular  agitation  whose  in- 
tensity arose  to  the  development  of  convulsions. 

Besides  the  evolution  of  hysteric  convulsions 
from  normal  emotional  reactions,  there  are  in- 
numerable ways  by  which  the  malady  can  be 
suggested  upon  the  patient.  About  5  or  10% 
of  the  cases  are  consequent  upon  operations. 
The  following  case  is  instructive    in    that    it 


Psycholepsy  235 

illustrates  how  the  seizures  may  be  elaborated 
from  a  surgical  experience ;  the  features  of  the 
attacks  being  derived  from  the  reactions  to 
etherization    and    from    associated    incidents : 

About  two  weeks  after  having  been  operated 
for  adenoids  a  boy  of  fifteen  commenced  to 
have  daily  crises.  These  occurred  at  the  same 
hour  each  day,  and  each  was  preceded  by  an 
aura  of  pain  in  the  left  side  of  his  abdomen, 
followed  by  difficulty  in  breathing,  a  sensation 
of  constriction  in  the  chest,  and  by  numbness 
and  tingling  of  the  whole  body.  Following 
these  sensations  he  seemed  to  become  uncon- 
scious and  general  convulsive  movements  ap- 
peared. The  whole  seizure  lasted  about  five 
minutes,  and  after  its  subsidence  he  felt  weak 
and  nauseated.  By  exerting  pressure  upon  the 
left  side  of  his  abdomen  the  attack  could  be 
reproduced. 

Now  this  peculiar  type  of  crisis  is  easily  ex- 
plained from  data  obtained  from  the  boy's 
father,  and  from  the  results  of  hypnotic  psycho- 
analysis. Being  greatly  alarmed  at  the  pros- 
pects of  the  operation,  which  had  been  per- 
formed one  year  previously,  the  patient  had  re- 
sisted etherization  so  much  that  an  orderly  had 
used  decided  force  in  holding  him  down.  Dur- 
ing these  struggles  the  efforts  of  the  orderly 
resulted  in  the  production  of  pain  in  the  left 
side  of  the  patient's  abdomen.  About  this  time 
the  effects  of    the    angesthetic    developed;    he 


236  Psychopathology  of  Hysteria 

began  to  experience  numbness  and  tingling  of 
the  body.  Local  irritation  from  forcing  the 
anassthetic  in  order  more  quickly  to  stop  his 
struggles  caused  a  feeling  of  suffocation.  After 
recovering  consciousness  naturally  he  felt  weak 
and  nauseated.  Thus  all  of  his  symptoms  may 
be  explained;  even  the  time  of  onset  of  his 
attacks  corresponded  to  the  time  of  the  opera- 
tion. Though  the  condition  had  lasted  a  year 
one  treatment  with  hypnotic  suggestion  effected 
a  satisfactory  cure. 

More  interesting  is  the  case  of  Marie ;  a  case 
reported  by  Janet,  who  asserts  that  it  is  one 
of  the  first  observations  concerning  subcon- 
scious fixed  ideas  in  a  hysteric:  Immediately 
before  each  menstrual  period  Marie  became 
sombre  and  violent.  Twenty  hours  after  the 
onset  of  menstruation  the  flow  suddenly  ceased, 
and  a  severe  chill  shook  her  whole  body.  Then, 
following  a  sharp  pain  that  arose  from  her 
abdomen  to  her  throat,  violent  convulsions  set 
in,  and  these,  in  turn,  were  succeeded  by 
maniacal  delirium.  (She  had  been  brought  to 
the  hospital  because  she  was  thought  to  be  in- 
curably insane.)  For  as  long  as  two  days  the 
stages  of  delirium  and  convulsions  alternated 
with  brief  periods  of  respite,  and  then,  after 
vomiting  blood  several  times,  her  usual  state 
of  consciousness  returned  and  she  was  amnesic 
for  the  whole  of  the  attack.  Being  questioned 
as  to  the  manner  in  which  her  first  menstrual 


Psycholepsy  237 

period  had  appeared,  and  had  been  interrupted, 
she  was  unable  to  answer  clearly;  she  seemed 
to  have  completely  forgotten. 

Having  remained  in  the  hospital  eight 
months  without  any  improvement  it  was  de- 
cided to  hypnotize  her,  and  then  to  endeavor 
to  ascertain  her  early  menstrual  history.  After 
inducing  the  somnambulistic  state  of  hypnosis 
Janet  was  enabled  to  discover  the  causes  of  the 
convulsive  seizures  and  of  other  symptoms 
which  do  not  concern  us.  When  Marie  had  at- 
tained the  age  of  thirteen  her  menses  first  ap- 
peared. Not  understanding  this  phenomenon, 
and  laboring  under  a  misapprehension  regard- 
ing its  cause,  she  was  ashamed,  and  sought  to 
suppress  the  flow.  To  this  end  she  went  out 
and  plunged  into  a  large  tub  of  cold  water. 
Twenty  hours  after  the  appearance  of  the  flow 
her  device  was  successful;  the  flow  suddenly 
ceased,  a  severe  chill  set  in,  she  was  delirious 
for  several  days  and  ill  for  a  considerable  time. 
Subsequently,  the  menses  did  not  reappear 
during  five  years  and,  finally,  when  they  did 
return,  they  were  accompanied  by  the  crises 
which  have  been  described.  The  onset  of  each 
menstrual  period  induced  reproduction  of  the 
pathologic  results  of  the  initial  suppression 
without,  however,  reviving  the  memory  of  the 
original  experience  itself.  Janet  incidentally 
remarks  that  by  modifying  the  subconscious 
idea  he  readily  caused  the  attacks    and    the 


238  PsycJiopathology  of  Hysteria 

delirium  to  disappear.  (Mental  State  of  Hys- 
tericals,  p.  282.) 

It  is,  indeed,  deplorable  that  a  prolific  cause 
of  hysteria  and  its  manifestations  is  the 
culpable  ignorance  of  young  girls  concerning, 
at  least,  the  menstrual  function.  Many  young 
girls  who  have  not  been  prepared  for  the  onset 
of  menstruation  become  so  alarmed  by  the  first 
indication  of  a  flow  that  they  develop  a  psy- 
choneurosis  with  the  consequence  that  each 
subsequent  menstrual  period  acts  as  the  ex- 
citant for  some  kind  of  attack.  Like  Janet 's 
case  the  manifestations  are  psycholeptic  in  not 
a  few  of  these  victims  of  a  faulty  system  of 
education.  Until  a  thorough  examination  had 
been  made  and  the  complete  history  obtained 
one  of  the  most  puzzling  diagnostic  problems 
was  presented  by  just  such  a  case.  A  young 
married  woman  had  been  perfectly  well,  from 
the  neurologic  point  of  view,  until  her 
thirteenth  year  when,  not  having  received  any 
instruction  relative  to  the  function  of  menstrua- 
tion, the  initial  onset  of  the  flow  so  frightened 
her  that  she  became  much  excited,  and  then 
maniacal.  Subsequently,  each  menstrual  period 
provoked  a  hysteric  crisis,  and,  as  the  years 
passed  hy,  these  seizures  gradually  became 
elaborated  until  they  resembled  epilepsy  so 
closely  that  this  diagnosis  had  been  made  by 
more  than  one  physician. 

Just   one   more    example   of  the   manner   in 


Psycholepsy  239 

which  psycholepsy  may  be  originated.     Sallie 
S.  had  been  subject  to  hysteric  crises  for  eight 
years.     At  first   her   seizures  were    character- 
ized only  by  uncontrollable  crying  and  laugh- 
ing, but  gradually  they  became  more  highly 
developed  so  that  finally  they  were  typical  of 
major   epilepsy.     It   was   found  that   she  had 
never    had     any    attacks,    nor   symptoms     of 
hysteria,  until  one  month  after  the  death  of  her 
first  child.     Upon  resorting  to  hypnosis  every- 
thing became  clear.     Each  attack  was  caused 
by     chance     occurrences,     or    remarks,   which 
caused  her  to  think  of  her  dead  child,  and  just 
preceding  the  onset  of  the  seizure  she  experi- 
enced hallucinations  concerning  the  illness  and 
the  death  of  this  child.    During  her  usual  state 
of   consciousness,   however,   she   positively   as- 
serted that  she  knew  of  no  cause  for  her  con- 
dition, and  that  she  did  not  believe  that  the 
death  of  her  child  had  anything  to  do  either 
with  the  illness  or  with  the  causation  of  indi- 
vidual   crises.     Besides    other  significant  fea- 
tures,  the   recovery    of    memories    of     events 
which  took  place  during  her  seizures,  and  the 
fact  that  she  has  not  had  a  single  convulsion 
since  the  first  hypnotic  treatment,  are  sufficient 
to  confirm  the  diagnosis — ^hysteric  psycholepsy. 
Every  emotion  tends    to  some    kind    of  ex- 
pression.    When  an  individual  suppresses  the 
reaction  he  performs  what  in  ordinary  parlance 
is  designated  a  bottling  up  of  emotion — instead 


240  Psychopathology  of  Hysteria 

of  dissipating  the  emotional  feeling  he  pre- 
serves it,  with  the  consequence  that  it  is  pro- 
longed only  to  crop  out  at  intervals.  It  is  a 
fact  of  common  observation  that  the  man  who 
gives  free  vent  to  his  wrath  soon  forgets  its 
cause,  while  he  who  suppresses  his  exhibition 
of  anger  does  not  soon  forget  the  provocation; 
his  anger  smoulders  within  him,  and  both  him- 
self and  its  object  long  continue  to  feel  its 
effects.  For  the  same  reason  the  most  intense 
grief  is  that  which  is  experienced  without  any 
outward  demonstration.  To  revert  to  the 
popular  recognition  of  the  effects  of  emotions 
which  have  not  been  adequately  expressed  we 
have  the  not  uncommon  remark — one  whose 
truth  is  affirmed  by  sound  psychologic  prin- 
ciples— that  is  made  about  an  afflicted  person: 
"If  she  could  only  cry  she  would  recover." 

We  know  that  dissociation  of  memory  com- 
plexes is  only  too  readily  effected  in  hysteria. 
When  a  hysteric  fails  sufficiently  to  react  to  an 
intense  emotion,  or  when  she  voluntarily 
strives  to  forget  the  painful  occurrence,  then 
the  complex  concerning  the  episode  becomes 
completely  submerged  into  subconsciousness. 
The  result  of  this  process  is  the  appearance 
of  some  kind  of  psychopathic  manifestation 
whenever  the  dissociated  complex  is  aroused 
into  activity  by  chance  association  of  ideas.  A 
hysteric  manifestation  once  having  occurred, 
the  proper  association  of  ideas  should  always 


Psycholepsy  241 

tend  to  reproduce  the  symptom,  just  as  the 
proper  stimulus  causes  us  to  remember  any 
event  in  our  lives ;  the  odor  of  a  rose  tends  to 
arouse  the  different  mental  images  pertaining 
to  the  conception  "rose,"  or  the  sight  of  the 
ocean  may  arouse  unpleasant  sensations  in  the 
epigastric  region  of  one  who  has  experienced 
seasickness. 

Among  other  interesting  clinical  studies  of 
the  genesis  and  subconscious  mechanism  of  dif- 
ferent psychoneurotic  manifestations  Sidis  re- 
lates the  history  of  a  case  which  perfectly  il- 
lustrates the  manner  in  which  association  of 
ideas  may  induce  recurrence  of  psycholeptic 
crises.  Part  of  his  account  is  as  follows:  "The 
patient  complains  of  'shaking  spells.'  The 
attack  sets  in  with  tremor  of  all  the  extremities 
and  then  spreads  to  the  whole  body.  The 
tremor  becomes  general  and  the  patient  is 
seized  by  a  convulsion  of  shivering  and 
tremblings  and  chattering  of  teeth.  Sometimes 
he  falls  down,  shivering,  trembling  and  shaking 
all  over.  The  seizure  seems  to  be  epileptiform, 
only  it  lasts  sometimes  for  more  than  three 
hours.  The  attack  may  come  on  any  time  dur- 
ing the  day,  but  is  more  frequent  at  night. 
During  the  attack  the  patient  does  not  lose 
consciousness,  he  knows  everything  that  is 
taking  place  around  him.  can  feel  everything 
pretty  well;  he  only  chatters  violently  with 
his  teeth,  trembles  and  shivers  all  over  and  is 


242  Psychopathology  of  Hysteria 

helpless  to  do  anything.  There  is  also  a  feeling 
of  chilliness,  as  if  he  is  possessed  by  an  attack 
of  'ague.'  The  seizure  does  not  start  with  any 
numbness  of  the  extremities,  nor  is  there  any 
anaesthesia  or  paraBsthesia  during  the  whole 
course  of  the  attack.  With  the  exception  of 
the  shivers  and  chills  the  patient  claims  he 
feels  'all  right.' 

"Patient  was  put  into  a  deep  hypnoidal  con- 
dition very  close  to  the  hypnotic  state.  There 
was  some  catalepsy  of  a  very  transient  char- 
acter, but  no  suggestibility  of  the  hypnotic 
type.  Now  in  this  hypnoidal  state  it  came  to 
light  that  the  patient  'many  years  ago'  was 
forced  to  sleep  in  a  dark,  damp  cellar  where 
it  was  bitter  cold.  The  few  nights  passed  in 
that  cold  cellar  he  had  to  leave  his  bed,  and 
shaking  and  trembling  and  shivering  and  chat- 
tering with  cold  he  had  to  go  to  urinate,  fear- 
ing to  wet  his  bed,  in  expectation  of  a  severe 
punishment.  The  patient,  while  in  that  inter- 
mediary, subwaking,  hypnoidal  state,  was  told 
to  think  of  that  dark,  damp,  cold  cellar.  Sud- 
denly the  attack  set  on, — the  patient  began  to 
shake  and  shiver  and  tremble  all  over,  chatter- 
ing with  his  teeth,  as  if  suffering  from  great 
cold.  The  attack  was  thus  reproduced  in  the 
hypnoidal  state.  '  This  is  the  way  I  have  them,  * 
he  said.  During  this  attack  no  numbness, 
no  sensory  disturbances,  were  present.  The 
patient  was  quieted,  and  after  a  little  while  the 


Fsycholepsy  243 

attack  of  shivering  and  cold  disappeared.  Now 
the  room  in  which  the  patient  was  put  into  the 
hypnoidal  state  was  very  dark,  and  acci- 
dentally the  remark  was  dropped  that  the 
room  was  too  dark  to  see  anything;  immedi- 
ately the  attack  reappeared  in  all  its  violence. 
It  was  found  later  that  it  was  sufficient  to  men- 
tion the  words  'dark,  damp,  and  cold'  to  bring 
on  an  attack  even  in  the  fully  waking  state. 
We  could  thus  reproduce  the  attacks  at  will, — 
those  magic  words  had  the  power  to  release 
the  pent-up  subconscious  forces  and  throw  the 
patient  into  convulsions  of  shakings  and  shiv- 
erings,  with  feeling  of  cold  and  chattering  of 
the  teeth."  (Studies  in  Psychopathology,  Bos- 
ton Med.  and  Surg.  Jour.,  Mar.  14,  1907,  to  Apr. 
11,  1907.) 

Often  trauma  is  one  of  the  factors  of  the 
emotional  stress  which  terminated  in,  or  was 
followed  by,  the  development  of  psycholeptie 
seizures.  The  memory  of  the  resultant  pain  be- 
comes, therefore,  a  constituent  of  the  complex 
of  the  original  experience.  In  fact,  the  part 
that  was  the  seat  of  pain  may  continue  in- 
definitely to  be  painful.  In  this  event  the  pain 
is  symbolic  of  the  accident.  Now,  just  as  the 
attacks  of  Sidis'  patient  were  precipitated  by 
arousing  the  idea  of  coldness,  of  darkness,  or 
of  dampness,  so  the  seizures  which  have  de- 
veloped after  traumatism  may  be  caused,  per- 
haps, to  recur  by  means  of  any  stimulus  which 


244  Psychopathology  of  Hysteria 

induces  the  idea  of  injury,  even  though  the 
patient  is  consciously  unaware  of  the  associa- 
tion between  this  idea  and  the  consequent 
attack. 

Naturally  pressure  on  the  area  which  orig- 
inally was  the  seat  of  trauma  is  the  most  ef- 
fectual mode  of  arousing  the  idea  of  injury,  or, 
by  association  of  ideas,  of  provoking  recurrence 
of  the  psycholeptic  state.  Such  being  the  case 
there  exist  what  truly  may  be  designated 
hysterogenic  zones.  These  zones  are  infrequent 
unless  created  by  suggestion,  and  when  they 
do  exist  the  induction  of  an  attack  by  means 
of  pressure  upon  the  zone  is  just  as  much  a 
psychic  phenomenon  as  the  effects  of  hearing 
the  words  ''dark,  damp  and  cold"  in  Sidis' 
patient.  In  either  case,  the  pressure,  or  the 
** hysterogenic"  words,  induce  by  subconscious 
association  of  ideas,  repetition  of  the  whole  of 
the  original  mental  state  and  precipitate  a 
crisis  that  is  identical  in  character  with  the 
original  reaction  unless  modified  by  elaboration 
or  by  contamination  through  admixture  with 
repetitions  of  the  reactions  of  other  experi- 
ences. 

If  we  hypnotize  a  subject  for  the  first  time 
and  then  cause  some  act  to  be  performed  after 
having  exerted  pressure  upon  some  part  of  his 
body  we  cause  an  association  of  ideas  between 
the  pressure  and  the  act.  The  second  time  that 
this   subject  is  hypnotized  pressure  alone    on 


Psycholepsy  245 

the  same  area  is  very  apt  to  be  followed  by  the 
same  act  that  was  performed  during  the  first 
hypnotic  state.  The  experiment  is  successful 
even  though  we  have  been  careful  to  avoid 
making  any  verbal  suggestions  which  would 
tend  to  produce  the  desired  result.  In  the 
same  manner  it  is  possible  to  manufacture 
hypnogenic  zones;  in  fact,  these  were  formerly 
described,  but  their  true  significance  was  not 
grasped.  A  hypnogenic  zone  is  the  analogue 
of  a  hysterogenic  zone,  and  there  is  nothing 
more  remarkable  about  either  of  these  than 
their  illustration  of  the  effects  of  association  of 
ideas. 

But  we  do  not  have  to  resort  to  hypnosis,  or 
to  the  hysteric,  in  order  to  observe  impressive 
examples  of  the  physical  effects  of  association 
of  ideas.  Those  occurring  under  normal  cir- 
cumstances are  equally  wonderful.  Pawlow's 
dogs,  for  instance,  exhibited  numerous  in- 
stances of  the  effects  of  association  of  ideas 
upon  the  secretion  of  the  digestive  fluids. 
Merely  attracting  the  attention  of  one  of  these 
dogs  to  food  acted  upon  the  secretion  of  saliva 
in  the  same  manner  as  when  it  was  actually 
placed  in  his  mouth.  This  psychologic  reflex 
could  be  aroused  by  association.  Thus:  "If  a 
definite  musical  note  be  repeatedly  sounded  in 
conjunction  with  the  exhibition  of  dry  meat- 
powder;  after  a  time  the  sound  alone  of  the 
note  is  effective.     Similarlv  with  the  exhibition 


246  Psychopathology  of  Hysteria 

of  a  brilliant  color."  (The  Work  of  the  Diges- 
tive Glands,  1910,  p.  85.) 

Recurrence  of  hysteric  crises  is  usually  ef- 
fected through  the  agency  of  mediate  associa- 
tion of  ideas.  As  the  pathogenic  memory  com- 
plex is  dissociated  from  consciousness  the 
hysteric  remains  unaware  of  the  underlying  as- 
sociation of  ideas — the  attacks  are  not  accom- 
panied by  conscious  recollection  of  the  original 
experience.  This  form  of  mediate  association 
of  ideas  in  itself  is  not  abnormal.  It  becomes 
so  only  when  its  results  are  abnormal.  Nor- 
mally one  idea  may  suggest  another  by  means 
of  a  third,  to  which  both  are  associated,  with- 
out necessitating  the  raising  of  this  third  idea 
above  the  level  of  consciousness.  In  other 
words,  the  association  of  the  two  ideas  takes 
place  through  the  subconscious  instrumentality 
of  one  which  is  common  to  both.  Though 
almost  invariably  cases  of  hysteria  present 
manifestations  which  are  the  result  of  mediate 
association  of  ideas  this  form  of  ideation  is  said 
to  be  uncommon  in  normal  life. 

Expectant  attention  may  induce  recurrence 
of  psychoneurotic  attacks.  This  fact  has  been 
the  subject  of  grave  misinterpretation.  When 
a  supposed  epileptic  announced  that  he  would 
have  a  seizure  at  such  and  such  an  hour  on  a 
certain  day,  and  when  this  came  about  just  as 
he  predicted,  then  the  case  was  recorded  as  an 
instance  of  wonderful,   or    supernatural,  pre- 


Psycholepsy  247 

vision.  Foissac's  Peter  Cazot  is  the  patient 
whose  case  has  been  most  frequently  cited.  The 
facts  of  this  case  and  the  protocol  of  the  ex- 
periment that  were  performed  with  the  patient 
were  included  in  the  report  to  the  R-oyal 
Academy  of  Paris,  in  1831,  of  the  Committee  of 
Investigation  of  Animal  Magnetism.  (Quoted 
by  Leger,  Animal  Magnetism,  1849,  p.  98.)  In 
commenting  upon  the  case  Leger  remarked  that 
notwithstanding  that  the  patient  could  indi- 
cate, a  month  or  two  in  advance,  the  day  and 
hour  at  which  he  was  going  to  have  a  convul- 
sion, yet  he  did  not  foresee  his  own  death  from 
an  accident  two  days  after  having  predicted 
the  cure  of  his  disease  at  a  date  three  months 
distant. 

The  explanation  of  the  '^ prevision"  of  psy- 
choneurotic attacks,  or  other  manifestations,  is 
simple.  When  a  psychopathic  individual  states 
that  he  will  have  an  attack  at  a  certain  time 
his  statement  constitutes  an  autosuggestion 
which  is  almost  sure  to  be  carried  out,  and 
when  the  patient  utters  the  prediction  while  in 
the  hypnotic  state,  as  did  Peter  Cazot,  the  auto- 
suggestion is  still  more  forcible. 

Very  often  psycholeptics  experience  aurae 
which  may  be  identical  with  those  of  epilepsy. 
Their  origin  can  be  discovered  only  by  means 
of  the  most  careful  researches  into  the  patient's 
subconsciousness,  and  then,  no  matter  how 
bizarre   and  inexplicable  they  may  have   ap- 


248  Psychopathology  of  Hysteria 

peared,  an  adequate  and  perfectly  reasonable 
cause  will  be  found.  The  perception  of  any 
sensory  stimulus  which  was  experienced  im- 
mediately preceding  the  pathogenic  emotional 
casualty,  or  its  consequent  first  attack,  may  be- 
come a  constituent  of  the  memory  complex 
which  has  to  deal  with  these  occurrences.  The 
more  intense  the  stimulus  and  the  more  closely 
associated  it  was  with  the  original  experience 
the  more  apt  is  its  memory  to  become  incor- 
porated with  the  resultant  complex.  Psycho- 
leptic  crises  are  stable — tend  to  recur  without 
variation — ^therefore,  before  each  subsequent 
attack  which  is  caused  by  a  direct  stimulus 
the  patient  should  experience  as  an  aura  the 
sensory  impression,  or  impressions,  which  pre- 
ceded the  first  attack.  Or,  any  accidental 
occurrence  which  recalls  the  memory  of  the 
precedent  sensory  perception  tends  to  cause 
repetition  of  the  attack  which  originally  fol- 
lowed this  perception. 

This  phenomenon,  too,  is  only  an  expression 
of  association  of  ideas  and  it  conforms  closely 
to  laws  which  have  been  induced.  William 
James  postulates  as  fundamental  the  law  that 
"When  two  elementary  brain-processes  have 
been  active  together  or  in  immediate  succession, 
one  of  them,  on  recurring,  tends  to  propagate 
its  excitement  into  the  other. "  (The  Principles 
of  Psychology,  vol.  1,  1905,  p.  566.)  And  ac- 
cording   to    Bain    ''Actions,    sensations,    and 


Psycholepsy  249 

states  of  feeling,  occurring  together  or  in  close 
succession,  tend  to  grow  together,  or  cohere,  m 
such  a  way  that  when  any  one  of  them  is  after- 
wards presented  to  the  mind,  the  others  are 
apt  to  be  brought  up  in  idea."  (The  Senses 
and  the  Intellect,  1864,  p.  332.) 

A  good  example  of  the  genesis   of  auras  is 
afforded  by   the   case   of  the   author   Gnstave 
Flaubert.      The   following   account   is   that    of 
Maxime   Du    Camp,   as    quoted    by     Grasset: 
''AH   at   once  without    any    apparent    reason 
Gustave  would  throw  up  his  head  and  become 
very  pale.    He  had  felt  the  aura.    His  look  was 
fuU    of    anguish.      He   would    say,  'I   have    a 
flame   in   my   left   eye;'   then   a   few   seconds 
later,  'I  have  a  flame  in  my  right  eye;  every- 
thing seems  to   me  to  be  the  color   of   gold.' 
This'' singular  condition  would  sometimes  per- 
sist for  ^several    minutes.       Then    his    visage 
would  grow  pale  again  and  take  on  a  desperate 
expression;  he  would  walk  about  rapidly;  then 
he  would   fairly  run  to   his  bed   and   stretch 
himself  out  on  it  dull  and  sinister  as  if  he  were 
Iving  alive  in  a  coffin.    Then  he  would  cry  out : 
'I  have  hold  of  the  reins !    Here  is  the  carrier ! 
I  hear  the  bells!     Ah!  I  see  the  lantern  of  the 
inn!'     Then  he  would  utter  a  cry  whose  pierc- 
ing accent  still  vibrates  in  my  ears,  and  a  con- 
vulsion would  then  come  on.     This  paroxysm, 
in  which  his  entire  body  trembled,  was  followed 
by    a    deep    sleep    and    profound    exhaustion 


250  PsychopatJiology  of  Hysteria 

which  lasted  for  several  days."  (The  Semi- 
Insane  and  the  Semi-Responsible,  trans,  by 
Jelliffe,  1907.)  The  cause  of  these  various 
hallucinatory  antecedents  of  a  convulsion  is 
plainly  made  evident  by  the  fact  that  the  first 
attack  occurred  ''in  the  neighborhood  of 
Bourg-Achard,  at  the  moment  when  a  post- 
carrier  was  passing  to  the  left  of  the  cabriolet, 
and  when  on  the  right  the  lights  of  a  lonely 
inn  were  perceptible  in  the  distance." 

Parker  writes  of  a  case  of  psychomotor  epi- 
lepsy in  which  the  convulsions  and  minor  at- 
tacks were  preceded  by  a  foul  taste  and  a  fetid 
odor.  This  aura,  one  which  is  not  uncommon 
in  epilepsia  vera,  was  found,  by  means  of  hyp- 
nosis, to  be  due  to  the  fact  that  just  prior  to  his 
first  seizure  the  patient  had  partaken  of  meat 
which,  by  reason  of  its  offensive  nature,  had 
caused  these  perceptions. 

These  cases  like  many  others  which  might  be 
quoted,  show  that  the  study  of  aurse,  because 
of  their  connection  with  the  emotional  first 
cause,  is  prolific  of  results,  both  in  etiologic  re- 
search and  in  therapeutic  indications. 

As  the  consciousness  of  the  patient  is  in  par- 
tial or  complete  abeyance  during  all  seizures, 
each  psycholeptic  attack,  of  hysteric  origin  at 
least,  is  a  more  or  less  complete  somnambulistic 
state  in  which  the  patient  experiences  subcon- 
sciously the  recurrence  of  some  former  emo- 
tional episode,  usually  the  exciting  cause  of  the 


Psycholepsy  251 

<f 
disease,  and  presents  a  repetition  of  the  original 

reactions  which,  however,  are  modified  by  the 
pathologic  elaboration  and  contamination  to 
which  the}^  have  been  subjected.  Indeed,  the 
character  of  the  crisis,  whether  convulsive  or 
delirious,  depends  almost  entirely  upon  the 
nature  of  the  hallucinations,  or  of  the  delusions, 
of  the  patient  at  the  time;  the  objective  symp- 
toms being  indicative,  therefore,  of  the  mental 
state  of  the  patient.  Being  somnambulistic 
states  these  attacks,  in  well  developed  cases 
either  of  psychasthenia  or  of  hysteria,  are  suc- 
ceeded by  amnesia  for  the  period  of  their 
duration. 

Psycholeptic  seizures  are  induced,  as  already 
intimated,  either  by  conscious  or  by  subcon- 
scious association  of  ideas  with  the  conscious, 
or  with  the  submerged,  memories  of  the  original 
painful  emotional  experience,  or  with  those  of 
any  antecedent  sensory  impression  which  united 
with  the  others  to  form  a  complex  of  the  pri- 
mary experience.  If,  as  an  exciting  cause  of  a 
psj^choneurosis,  an  individual  who  is  predis- 
posed by  psychopathic  heredity  is  subject- 
ed to  a  relatively  severe  emotional  shock 
any  subsequent  psychic  stimulus  which,  by 
association  of  ideas,  recalls  this  experience 
thereby  will  tend  to  cause  recurrence  of  its 
original  reactions,  or  motor  expression,  in  an 
elaborated  and  pathologic  manner.  In  hys- 
teria the  whole  mechanism  is  more  or  less  sub- 


252  Psychopathology  of  Hysteria 

conscious;  the  patient  usually  being  absolutely 
ignorant,  as  far  as  consciousness  is  concerned, 
of  any  reason  for  the  onset  of  each  attack. 
This  fact  has  been  explained  biologically  by 
assuming  that,  as  a  reaction  of  defense,  there 
occurs  voluntary  suppression  from  conscious- 
ness of  the  memories  of  the  primary  experi- 
ence. 

Modern  psychopathologic  researches  in- 
contestably  have  shown  that  what  appears  to 
be  absolute  loss  of  memory  of  the  causes  and 
events  of  each  attack  is,  in  reality,  always 
functional  amnesia ;  one  which  is  due  to  disso- 
ciation or  splitting  off  from  consciousness  of 
the  system  of  memories  concerning  the  original 
stress  and  each  subsequent  crisis,  and  that 
these  dissociated  or  submerged  complexes  are 
preserved  in  subconsciousness,  from  which  they 
can  be  tapped  by  means  of  association  experi- 
ments, hypnoidization,  hyponotization,  auto- 
matic writing,  analysis  of  reveries  and  dreams, 
etc. 

Though  the  whole  mechanism  of  hysteric  ac- 
cidents is  subconscious  it  appears  that  in  psy- 
chasthenia  the  patient  is  usually  superficially 
aware  of  the  causes  of  his  symptoms.  In  other 
words,  hysteric  manifestations  are  caused  by 
subconscious  association  of  ideas,  while  those  of 
psychasthenia  are  usually  caused  by  conscious 
association  of  ideas.  Furthermore,  it  is  by 
reason  of  fear  and  expectant  attention  that  the 


Psycholepsy  253 

crises  of  psychasthenia  are  commonly  induced. 
It  is  important  to  remember,  however,  that  the 
conscious  fear  and  the  conscious  expectancy 
are  purely  obsessions  which  are  originated  by 
dissociated  components  of  normal  conscious- 
ness. 

In  about  50-80%  of  those  who  are  hypnotized 
the  dissociation  of  consciousness  is  so  profound 
that  after  being  '^wakened"  the  subject  is  in- 
capable of  remembering  consciously  any  of  the 
events  of  the  hypnotic  state.  While  one  of 
these  hypnotic  somnambulists  is  h^^Dnotized 
suppose  we  suggest  to  him  that  when  he  sees 
us  put  on  our  glasses,  after  he  is  wakened,  he 
will  perform  a  certain  specified  act — light  the 
gas,  for  instance.  Being  a  somnambulist  he 
does  not  remember  this  suggestion  after  the 
hypnotic  state  is  dispelled ;  we  have  dissociated 
from  his  consciousness  a  certain  system  of  ideas 
just  as  complexes  become  submerged  in 
hysteria.  Now,  upon  adjusting  our  glasses  the 
subject  is  most  apt  to  carry  out  the  post  hyp- 
notic suggestion  which  was  imparted  to  him, 
without,  however,  knowing  the  true  reason  for 
doing  so.  Through  the  agency  of  subconscious 
association  of  ideas  our  stimulus  arouses  into 
activity  the  dissociated  complex  which,  in  turn, 
induces  the  idea  of  lighting  the  gas.  Being 
ignorant  of  the  true  reason  for  his  act  he  un- 
consciously substitutes  some  specious  motive  — 
a  very  human-like  procedure  —  and  this  he  will 


254  Psychopathology  of  Hysteria 

present  as  Ms  reason  if  asked  why  he  lighted 
the  gas  in  view  of  the  fact  that  further  illu- 
mination is  unnecessary. 

In  this  manner  we  have  completely  dupli- 
cated the  psychic  mechanism  of  a  hysteric  at- 
tack, and  it  would  be  just  as  easy  to  substi- 
tute convulsions  for  the  simple  act  of  lighting 
the  gas.  On  the  other  hand,  suppose  our  sub- 
ject is  not  a  somnambulist  —  suppose  that  after 
being  wakened  he  does  remember  the  events  of 
hypnosis.  Then  we  have  a  mechanism  which 
is  similar  to  that  of  a  psychasthenic  manifesta- 
tion. "Wlien  we  put  on  our  glasses  he  becomes 
obsessed  with  the  idea  of  lighting  the  gas,  but 
he  is  aware  of  the  exact  source  of  this  impulse. 

To  illustrate  the  difference  between  the  psy- 
cholepsy  of  hysteria  and  that  of  psychasthenia 
let  us  adduce  a  case  of  each  of  these  mala- 
dies. A  male,  aet.  19,  was  knocked  from  a  box, 
and  fell,  striking  his  head  in  the  occipital 
region.  The  injury  resulted  in  immediate  un- 
consciousness which  lasted  only  for  two  or 
three  minutes.  Following  this  accident  he  was- 
perfectly  well  except  that  he  had  a  moderate 
headache  for  several  hours.  At  this  time  his 
father,  for  whom  he  cared  to  an  extent  which 
was  considered  unusual,  was  acutely  ill  for  ten 
days,  and  then  died,  after  having  had  a  con- 
vulsion. When  the  patient  learned  of  "  his 
father's  death  he  was  seized  with  severe  pain 
in  the  head,  fell  unconscious,  and  presented  the 


Psycholepsy  255 

typical  manifestations  of  a  major  epileptiform 
convulsion  similar  to  the  one  which  had  oc- 
curred in  his  father  and  of  which  he  had  re- 
ceived a  graphic  description.  Subsequently, 
and  at  intervals  of  about  a  month,  the  seizures 
recurred;  each  being  preceded  by  pain  in  the 
head.  The  later  attacks,  beside  being  char- 
acteristic otherwise  of  those  of  epilepsy,  be- 
came contaminated  with  symptoms  of  hysteria. 
Being  questioned  he  professed  absolute  ignor- 
ance of  the  cause  of  these  crises. 

After  inducing  the  hypnotic  state  it  was 
demonstrated  that  he  was  perfectly  cognizant 
of  what  was  going  on  about  him  during  his 
seizures,  and  he  acknowledged  that  each  fol- 
lowed allusions  to  his  father,  or  to  death,  al- 
though he  had  been  unaware  of  this  sequence 
when  in  his  usual  state  of  consciousness.  Dur- 
ing convulsions,  thoughts  of  his  father  occupied 
his  mind,  and  he  felt  that  he  must  go  to  him. 
Each  crisis,  therefore,  was  a  somnambulistic 
state  resulting  from  chance  occurrences  which, 
by  unconscious  association  of  ideas,  provoked 
the  elaborated  reproduction  of  his  emotional 
reactions  to  the  shock  produced  by  learning  of 
his  father 's  death.  The  aura  of  his  attacks  — - 
pain  in  the  head — is  capable  of  being  inter- 
preted as  a  hallucinatory  recurrence  of  the 
headache  resulting  from  the  fall  which  was  so 
closely  associated,  in  time,  with  his  father's 
fatal  illness. 


256  Psychopathology  of  Hysteria 

The  following  case  is  in  decided  and  typi- 
cal contrast  to  the  one  just  summarized.  A 
psychasthenic  male  who  had  just  had  an  at- 
tack which  very  closely  simulated  petit  mal 
stated  that  prior  to  its  onset  he  was  not  think- 
ing of  himself,  or  of  any  of  his  symptoms,  until 
a  friend  began  to  discuss  a  relative's  death 
from  heart  disease.  At  once  he  was  impelled 
to  think  of  his  own  cardiac  attacks,  and,  after 
a  short  period  of  fear  and  expectant  attention, 
the  symptoms  appeared  which  were  character- 
istic of  one  of  his  ov^^n  seizures.  This  patient 
was  always  aware  of  the  association  of  ideas 
which  preceded  his  attacks,  and  he  appreciated, 
in  a  self-condemnatory  manner,  the  genetic  in- 
fluence of  his  fear  and  expectancy. 

An  intelligent  psychasthenic  will  often  ad- 
mit voluntarily  that  his  attacks  are  due  to  the 
provocation  of  fear  and  expectancy  by  asso- 
ciation of  ideas,  and  even  the  dispensary 
patient  generally  realizes,  after  a  few  words  of 
explanation,  that  his  seizures  are  caused  in 
this  manner.  It  appears,  nevertheless,  that  the 
greater  part  of  the  mechanism  of  genesis  of 
individual  seizures  may  be  subconscious  in  a 
few  cases  of  psychasthenia. 

Another  notable  differentiating  feature  be- 
tween the  psycholepsy  of  hysteria  and  that  of 
psychasthenia  is  the  curious  fact  that  a  hysteric 
is  rarely  inconvenienced  or  distressed  by  the 
occurrence  of  attacks,  no  matter  how  severe 


Psycholepsy  257 

or  incongruous  they  may  be,  while  to  the  psy- 
chasthenic each  is  characterized  by  the  greatest 
anguish. 

For  the  reason  that  the  prognosis  and  treat- 
ment of  the  psychoneuroses  is  necessarily  so 
dissimilar  from  that  of  epilepsy  a  correct 
diagnosis  is  most  essential.  Another  cogent 
reason  for  diagnostic  precision  is  afforded  by 
the  incalculable  amount  of  harm  which  may 
result  from  the  psychic  stress  provoked  by  in- 
forming a  hysteric,  or  psychasthenic,  that  he 
is  afflicted  with  epilepsy;  a  disease  which  is 
looked  upon  with  so  much  horror  by  the  laity, 
and  which  is  believed  by  them  to  be  incurable 
and  stigmatic.  In  view  of  these  facts,  then,  it 
is  incumbent  upon  us  to  exercise  constantly 
the  greatest  care  in  order  to  prevent  mistaking 
hysteria  or  psychasthenia  for  epilepsy,  or  vice 
versa.  Indeed,  some  cases  may  require  several 
weeks,  or  months,  of  careful  study  by  an  ex- 
pert psycho-pathologist  before  a  definite  diag- 
nosis can  be  made. 

As  recent  research  has  shown  that  epilepsy 
is  incapable  of  causing  any  symptoms  which 
cannot  be  duplicated,  or  at  least  simulated,  by 
hysteria  and  psychasthenia,  and  as  the  crises, 
therefore,  of  these  psychoneuroses  may  be 
identical  with  those  of  epilepsy,  we  are  unable 
now  to  make  the  diagnosis  epilepsy  simply 
because  a  patient  is  afflicted  with  seizures 
which  conform  to  the  classical  text-book  de- 


258  Psychopathology  of  Hysteria 

scriptions  of  those  which  are  supposed  to  be 
characteristic  of  this  disease.  It  is  only  by 
careful  consideration  of  the  results  of  some 
psychoanalytic  method  which  reveals  the  sub- 
conscious activities  of  the  patient  that  we  can 
differentiate,  in  almost  a  positive  manner,  the 
most  highly  developed  types  of  hysteric  and 
psychasthenic  attacks  from  those  due  to 
epilepsy.  In  a  few  cases  the  diagnosis  psycho- 
lepsy  can  be  made  positively  only  when  the 
patient  has  been  ''cured"  in  a  short  time  by 
some  therapeutic  measure  which  is  effective 
only  in  that  condition.  As  all  of  the  symptoms 
of  an  epileptic  attack  can  be  duplicated  by 
psycholepsy  the  basis  of  differential  diagnosis 
may  be  considered  from  the  point  of  view  of 
the  psychoneuroses. 

Psycholepsy 

1.  Attacks  are  due  either  to  conscious  or  to 
subconscious  association  of  ideas. 

2.  The  attacks  in  a  given  case  are  always 
of  a  like  nature  unless  variation  occurs  as  the 
result  of  plurality  of  primary  stresses. 

3.  Prevention  of  attacks  by  means  of  sug- 
gestion, or  of  other  psychotherapeutic  means. 
(It  seems  more  than  improbable  that  a  case  of 
true  epilepsy  has  ever  been  cured  by  means  of 
psychotherapy  alone.) 

4.  Induction  of  attacks  through  the  agency 
of  suggestion. 


Psycholepsy  259 

5.  Susceptibility  of  the  patient  to  sugges- 
tion during  the  height  of  a  crisis. 

6.  Bromide  treatment  does  not  favorably 
influence  the  seizures  and  usually  aggravates 
the  other  symptoms. 

7.  In  those  cases  in  which  the  crises  have 
persisted  many  years  intelligence  and  memory 
do  not  deteriorate  progressively.  Amnesia,  if 
present,  is  purely  functional  in  character,  and 
events  which  apparently  have  been  forgotten 
are  capable  of  being  recovered  by  means  of 
hj^pnosis  and  certain  other  well  known  pro- 
cedures. 

8.  The  discovery,  through  some  psychoan- 
alytic method,  of  a  wealth  of  pathogenic  and 
dissociated,  or  subconscious  ideation. 

9.  Conservation  in  subconsciousness  of  the 
memories  of  events  which  occurred  during 
seizures.  Demonstration  of  this  conservation 
of  memories  by  causing  reproduction  through 
the  agency  of  methods  which  have  already  been 
mentioned. 

It  is  to  be  hoped  that  some  competent  inves- 
tigators who  possess  the  requisite  opportunities 
wiU  interest  themselves  in  researches  having 
as  their  end  the  corroboration  of  what  theoreti- 
cally has  been  assumed,  and  to  a  certain  extent 
demonstrated :  that  in  epileptics  it  is  impossible 
by  any  known  means  to  recover  memories  of 
events  which  happened  during  the  height  of  a 


260  Psychopathology  of  Hysteria 

convulsion.  The  recovery  of  such  memories 
may  be  accepted,  however,  as  unimpeachable 
evidence  of  the  psychogenic  nature  of  a  con- 
vulsion; no  matter  hov7  typical  otherwise  of 
epilepsy  it  may  have  seemed.  This  statement 
may  appear  to  be  too  conclusive,  but  in  all  the 
literature  at  my  command  I  have  been  unable 
to  discover  any  case  of  undoubted  epilepsy  in 
which  the  memories  of  events  which  occurred 
during  attacks  were  successfully  reproduced, 
and,  on  the  other  hand,  investigators  who  have 
succeeded  in  reproducing  such  memories  in 
supposed  cases  of  epilepsy  unite  in  saying  that 
the  cases  have  always  turned  out  to  be  ones  of 
psycholepsy. 

Inasmuch  as  the  existence  either  of  epilepsy 
or  of  psychoneuroses  in  the  progenitors  may 
cause  the  development,  in  the  offspring,  of  any 
of  the  conditions  under  discussion,  the  dis- 
covery of  neuropathic  heredity  is  not  of  great 
importance  in  the  differential  diagnosis  of 
epilepsy,  hysteria,  and  psychasthenia. 

When  in  doubt  as  to  the  cause  of  convulsions 
it  is  Bernheim's  custom  to  press  upon  the 
abdomen,  or  other  region  in  which  the  aura 
commences,  while  making  the  suggestion  that 
the  pressure  will  be  painful ;  then  that  the  globe 
rises  in  the  throat,  and  that  the  patient  feels 
her  crisis  approaching.  In  this  manner  he 
creates  a  hysterogenic  zone  and  causes  the 
onset  of  an  attack.     In  the  great  majority  of 


Psycholepsy  261 

cases,  he  affirms,  the  crises  are  capable  of  being 
provoked  experimentally  by  this  means,  and 
without  the  induction  of  the  hypnotic  state. 
Having  succeeded  in  reproducing  the  crisis  he 
considers  that  the  diagnosis  hysteria  is  con- 
firmed, and  that  the  condition  is  curable. 
(Hypnotisme  et  Suggestion  Hysteric  Psy- 
chonevroses,  1910,  p.  255.) 

The  knowledge  possessed  by  epileptics  that 
they  are  afflicted  with  an  incurable  organic 
nervous  disease ;  the  severity  of  the  symptoms 
of  this  disease ;  and  the  unexpected  manner  in 
which  old  symptoms  may  recur,  or  new  ones 
suddenly  appear,  together  with  the  state  of 
fear  and  expectant  attention  which  thereby 
is  ultimately  provoked,  often  leads  to  the  de- 
velopment of  a  superimposed  psychoneurosis. 
Consequently,  the  fact  that  a  patient  presents 
the  hysteric  or  psychasthenic  type  of  tempera- 
ment, in  addition  to  the  discovery  of 
"stigmata"  of  either  of  these  conditions,  does 
not  necessarily  eliminate  the  possibility  of  the 
coexistence  of  epilepsy.  As  a  matter  of  fact  it 
is  not  at  all  unusual  for  epileptic  and  psy- 
choleptic  seizures  to  alternate. 

As  to  the  prognosis  of  psycholepsy  and  of 
other  psychogenetic  seizures :  When  the  at- 
tacks occur  in  cases  of  hysteria  the  results  of 
treatment  are  excellent,  and  a  symptomatic 
cure  is  to  be  expected  in  all  cases.  It  is 
singular,  indeed,  that  one  of  the  most  severe  of 


262  Psychopathology  of  Hysteria 

the  major  symptoms  should  be  so  amenable  to 
treatment.  In  my  own  experience  it  has  re- 
quired only  a  few  weeks  to  overcome  the 
psycholeptic  habit  of  about  95%  of  hysteric 
patients  and  in  the  majority  of  these  the 
seizures  have  failed  to  recur  after  the  first 
treatment.  Bernheim  writes:  "After  an  ex- 
perience of  20  years,  I  affirm  that,  except  those 
confirmed  cases  in  whom  the  hysterogenic 
automatism  has  become,  so  to  speak,  a  cerebral 
localization,  the  crises  always  can  be  perman- 
ently dissipated,  formerlj^  I  said  by  hypnotic 
suggestion;  to-day  I  say  by  education  of  the 
will  of  the  patient."  (Conception  Du  Mot 
Hysteric,  1904,  p.  8.) 

If  the  attacks  are  symptomatic  of  psychas- 
thenia  the  results,  though  good,  are  not  so 
favorable  as  those  obtained  in  hysteria.  The 
difference  in  the  prognosis  of  these  two  diseases 
is  readily  comprehended  by  taking  into  consid- 
eration the  difference  in  the  mental  states  char- 
acteristic of  the  two  conditions.  Cases  of 
hysteria  are  eminently  suitable  for  the  appli- 
cation of  psychotherapy  because  the  proper 
suggestions  are  more  apt  to  be  accepted  un- 
critically and  without  any  resistance.  Unfor- 
tunately, in  psychasthenia  the  hypnotic  state  is 
usually  secured  with  difficulty  because  of  the 
inability  of  the  patient  to  concentrate  his  at- 
tention by  reason  of  the  distracting  influence 
of  fear  and  of  extraneous  ideas.     More  or  less 


Psycholepsy  263 

unconscious  and  antagonistic  autosuggestion 
also  interferes  greatly,  in  these  cases,  both  with 
the  production  of  the  hypnotic  state,  and  with 
the  acceptance  of  therapeutic  suggestions  after 
this  state  is  secured.  In  response  to  each  sug- 
gestion of  the  physician  the  patient  seems  im- 
pelled to  expect  the  contrary  to  occur.  If 
psychotherapy  is  adopted  without  attempting 
to  induce  hypnosis  the  same  difficulties  are  en- 
countered, but  then  they  are  more  troublesome. 
The  manner  in  which  the  attacks  of  hysteria 
should  be  treated  is  rendered  evident  by  pos- 
sessing knowledge  of  the  psychic  mechanism  of 
the  conditions  which  may  cause  this  clinical 
phenomenon.  If,  for  example,  a  certain  stim- 
ulus, or  a  certain  kind  of  stimuli,  is  found  to 
cause  recurrence  of  the  aura,  either  by  con- 
scious or  by  subconscious  association  of  ideas, 
and  thereby  to  precipitate  a  crisis,  then  one  of 
the  first  principles  of  treatment  is  to  abolish 
this  tendency.  The  same  applies  to  reproduc- 
tion of  seizures  by  either  form  of  association  of 
ideas  with  any  other  component  of  the  dormant 
complex.  To  do  this  in  a  scientific,  effective 
and  lasting  manner  requires  synthesis  with  the 
patient's  consciousness  of  the  dissociated  and 
pathogenic  complexes.  Naturally  this  proce- 
dure necessitates  discovery,  by  means  of  some 
psychoanalytic  method,  of  the  submerged  com- 
plexes, and  then  their  reintegration  with  con- 
sciousness by  means  of  inducing    the    patient 


264  Psychopathology  of  Hysteria 

consciously  to  remember  the  original  painful 
experience  and  its  emotional  consequences. 

Even  though  at  first  it  may  seem  highly  im- 
probable that  a  patient  may  be  cured  of  certain 
nervous  manifestations  by  causing  him  to  recall 
some  painful  episode  in  his  life,  it  is,  neverthe- 
less, a  fact  which  is  quite  generally  known. 
In  writing  of  this  peculiarity,  as  it  occurs  in 
hysteria,  Freud  remarks :  ' '  We  found,  at  first 
to  our  greatest  surprise,  that  the  individual 
hysterical  symptoms  immediately  disappeared 
without  returning  if  ive  succeeded  in  thoroughly 
awakening  the  memories  of  the  causal  process 
with  its  accompanying  effect,  and  if  the  patient 
circumstantially  discussed  the  process  giving 
free  play  to  the  effect.^'  (Selected  Papers  on 
Hysteria,  Trans,  by  A.  A.  Brill,  1909,  p.  4.) 

Let  us  see  how  Bernheim  treats  with  simple 
suggestion  his  psycholeptic  patients.  Having 
succeeded  in  reproducing  a  crisis,  he  afSrms 
positively  before  the  patient  and  his  students 
that  cure  is  certain.  Whether  he  has  produced 
the  crisis  himself,  or  he  is  called  upon  to  treat 
one  which  has  appeared  spontaneously,  he 
dissipates  the  attack,  usually  within  three 
minutes,  by  suggesting  progressively  the  dis- 
appearance of  the  various  symptoms.  After  he 
has  provoked  a  crisis  and  then  dissipated  it, 
he  commences  to  re-educate  the  patient  in  order 
to  teach  her  to  inhibit  the  seizures.  His 
method  of  suggestion  is  to  say  to  the  patient: 


Psycholepsy  265 

''You  see  that  I  have  been  able  to  bring  on  a 
seizure  and  to  stop  it.  I  can  also  prevent  you 
from  having  them.  To  prove  it  I  will  now  press 
on  the  same  spot  where  pressure  provoked  an 
attack  a  little  while  ago,  and  this  time  the 
crisis  will  not  appear.  You  will  feel,  perhaps, 
as  if  one  was  about  to  appear;  but  it  will  not 
do  so."  At  first  he  touches  lightly,  and  then 
gradually  increases  the  pressure  upon  the 
region  which  had  been  rendered  hysterogenic. 
Often  the  patient  becomes  excited ;  her  respira- 
tion becomes  panting;  she  feels  the  globus 
hystericus;  the  crisis  is  imminent.  He  smiles, 
however,  and  reassures  her  by  saying:  "Calm 
yourself;  the  attack  will  not  come.  You  will 
remain  master  of  yourself."  This  suggestive 
lesson  is  repeated  every  day,  and  it  is  rare,  he 
asserts,  that  cure  is  not  obtained  in  three  days. 
His  object  is  to  teach  the  patient  to  control  her- 
self and  to  restore  to  her  the  confidence  in  her- 
self which  she  has  lost.  (Hypnotisme  &  Sug- 
gestion, 1910,  p.  255). 

There  are  certain  only  too  popular  forms  of 
treatment  of  hysteric  attacks  which  cannot 
be  condemned  too  strongly.  Many  hospital 
internes  inject  apomorphine  into  every  hysteric 
that  comes  into  the  receiving  ward  during  a 
seizure.  No  doubt  this  procedure  is  very  effica- 
cious; the  attack  coming  to  a  sudden  termina- 
tion with  the  onset  of  vomiting.  But,  one 
would  have  just  as  good  reason  to  apply  the 


266  Psychopathology  of  Hysteria 

same  treatment  to  a  child  because  it  cries.  Be- 
side the  fact  that  recurrence  of  seizures  is  not 
prevented  by  forcible  suppression,  particularly 
by  a  punitive  measure — for  that  is  what  hypo- 
dermic injection  of  apomorphine  may  be  con- 
sidered to  be  when  used  in  the  treatment  of 
hysteria — the  treatment  is  decidedly  harmful. 
By  reason  of  the  suggestibility  which  is  char- 
acteristic of  hysteria,  it  is  not  at  all  improb- 
able that  many  cases  that  have  been  treated 
in  this  manner  present  vomiting  as  a  feature  of 
subsequent  attacks. 

Some  authors  advise  inhalations  of  ether  or 
of  chloroform  in  the  treatment  of  severe  hys- 
teric attacks.  Such  measures  must  be  effec- 
tive, but  they  certainly  should  increase  the 
resistance  of  the  disease  to  subsequent  treat- 
ment, and  they  remind  one  of  the  man  who 
resorted  to  a  sledge  hammer  in  order  to  kill  a 
flea.  The  administration  of  morphine  is  espe- 
cially pernicious.  Not  only  is  such  treatment 
merely  palliative  of  the  immediate  attack  but 
it  establishes  a  harmful  precedent,  which  may 
be  followed  by  development  of  a  drug  habit. 
Bromides,  too,  are  injurious,  in  that  they  have 
a  depressing  effect  when  administered  in  large 
doses,  and  they  tend  to  produce  a  stuporous 
condition  which  may  become  elaborated  into 
a  variety  of  hysteric  manifestations.  More- 
over, these  drugs  do  not  have  any  effect  upon 
the  convulsive  habit.    Valerian,  asafoetida  and 


Psycholepsy  267 

the  like  are  not  detrimental ;  neither  are  they 
beneficial,  save  by  reason  of  the  fact  that  their 
peculiarly  offensive  odor  may  lead  the  patient 
to  believe  that  she  is  taking  some  powerful 
drug  which  may  cure  her.  One  well-known 
authority  advises  a  restraining  sheet  or  a 
straight- jacket  in  order  to  control  patients  with 
severe  convulsions ! 


CHAPTER  VIII 

Alterations  of  Consciousness 

MORBID  Somnolent  States  and  Nar- 
colepsy. Morbid  somnolence  consists 
in  a  prolonged  sleep-like  state,  while 
narcolepsy  is  characterized  by  periods 
of  sudden  irresistible  inclination  to  sleep  which 
may  occur  at  any  time,  regardless  of  the  sur- 
roundings of  the  patient  and  of  what  he  is  do- 
ing at  the  moment.  The  majority  of  cases  of 
narcolepsy  have  probably  been  due  to  organic 
disease.  Inasmuch  as  experimental  investigation 
has  resulted  in  reasonable  doubt  concerning  the 
existence  of  psychic  epilepsy,  it  is  possible,  also, 
that  what  is  supposed  to  be  epileptic  narcolepsy 
is  really  a  manifestation  of  hysteria.  All  of  the 
few  cases  of  typical  narcolepsy  that  have  come 
under  my  observation  have  been  due  to  hys- 
teria. One  patient,  a  known  hysteric,  devel- 
oped narcoleptic  seizures  that  occurred  fre- 
quently during  the  day  and  which  caused  her 
to  go  to  sleep  even  while  working  around 
machinery  that  might  have  injured  her,  and 
even  though,  on  account  of  her  infirmity,  she 
was  in  danger  of  losing  her  position.  Besides 
other  features  of  the  case,  the  fact  that  several 
treatments  with  hypnotic  suggestion  effected  a 
cure  is  sufficient  evidence  for  the  exclusion  of 
organic  disease.    During  sixteen  years  Weisen- 

268 


Alterations  of  Consciousness  269 

burg's  patient  had  been  subject  to  frequent 
attacks  of  morbid  somnolence  that  occurred  at 
any  hour  of  the  day.  She  had  been  known  even 
to  sleep  while  standing.  In  spite  of  the  long 
duration  of  the  affection,  the  patient  was  being 
rapidly  cured  by  psychotherapy.  (Jour,  of 
Nerv.  and  Ment.  Dis.,  1909,  p.  367). 

There  is  no  reason  for  looking  upon  func- 
tional narcolepsy  with  a  degree  of  surprise  and 
wonderment  greater  than  we  bestow  upon  psy- 
cholepsy  and  its  mode  of  genesis.  The  mechan- 
ism is  the  same  in  each,  and  the  manifestations 
of  convulsive  seizures  differ  from  those  of  the 
narcoleptic  attacks  of  hysteria  only  in  that 
the  former  include  various  psychomotor  phe- 
nomena in  addition  to  a  subconscious  state, 
Objectively,  hysteric  narcolepsy  represents 
only  the  fixation  of  a  lapse  of  consciousness, 
while  in  the  case  of  hysterogenic  convulsions 
the  primar}^  emotional  reaction  is  repeated 
more  or  less  completely,  and,  during  the  course 
of  repetition,  perhaps  becomes  developed  and 
expanded.  For  instance,  as  a  reaction  to  some 
disagreeable  experience  a  hysteric  faints. 
Subsequently  a  state  of  hysteric  narcolepsy  is 
induced  by  casual  references  to  this  event,  or 
by  any  stimuli  which  by  subconscious  associa- 
tion of  ideas  arouse  into  activity  the  submerged 
complex  of  the  occurrence. 

That  psychologic  gold  mine,  the  Beauchamp 
case,  furnishes  a  particularly  fine  instance  of 


270  Psychopathology  of  Hysteria 

trance-like  states  brought  about  by  association 
of  ideas  with  the  memories  of  sensory  percep- 
tions which  were  contemporaneous  with  the 
onset  of  a  syncopal  attack.  While  preparing  to 
retire,  Miss  B.  had  fallen  into  a  trance.  Believ- 
ing that  pathologic  association  of  ideas  was  the 
cause  of  this  occurrence,  Prince  inquired  into 
the  matter.  The  result  of  his  investigations 
was  as  follows:  "Just  before  going  into  the 
trance  she  found  herself  thinking  of  an  old 
girl  friend.  How  she  came  to  be  thinking  of 
this  friend  she  did  not  know,  but  this  girl  once 
gave  her  a  severe  nervous  shock,  and  she  has 
noticed  that  the  occasion  of  going  into  trances 
of  late  years  almost  always  has  been  while 
thinking  of  this  girl,  or  while  hearing  certain 
music,  or  the  sound  of  the  wind,  or  while  feel- 
ing the  air  blowing  on  her  face,  and  other 
sensations,  all  of  which  are  associated  with 
this  friend." 

"It  came  about  originally  in  this  way:  A 
long  time  ago,  while  in  church  and  while  the 
organist  was  playing  the  Hallelujah  Chorus 
from  Handel's  Oratorio,  this  friend  leaned  to- 
wards her  and  told  her  something  that  gave  her 
a  severe' shock, — much  as  if  she  had  told  her 
the  news  of  someone 's  death.  At  the  same  time 
she  smelled  the  odor  of  incense  in  the  church, 
heard  the  wind  blowing  through  the  open  win- 
dow, and  felt  it  on  her  face.  All  this  she  was 
distinctly  conscious  of  at  the  time,  as  well  as 


Alterations  of  Consciousness  271 

of  the  nervous  shock.  Then  she  remembered 
nothing  more  for  a  few  minutes.  Now  any- 
thing that  recalls  this  girl,  or  the  scene  in  the 
church  to  her  mind, — such  as  the  Hallelujah 
Chorus,  the  smell  of  incense,  the  sound  of  the 
wind,  or  the  wind  blowing  on  her  face, — is  apt 
to  send  her  into  a  trance."  (The  Dissociation 
of  a  Personality,  1906,  p.  88). 

A  typical  example  of  the  manner  in  which 
individual  attacks  may  be  reproduced  as  the 
effect  of  association  of  ideas  is  furnished  by 
some  incidents  directly  resulting  from  the 
faulty  methods  of  hypnosigenesis  formerly 
employed  at  the  Salpetriere.  In  this  institution 
hysteric  patients  were  customarily  hypnotized 
by  means  of  intense  sensorial  excitation ;  a 
flash  of  bright  light,  the  sound  of  a  gong,  etc., 
being  employed.  After  having  been  discharged 
from  the  hospital  more  than  one  patient  has 
developed  a  lethargic  or  cataleptic  state  as  the 
consequence  of  a  sudden  flash  of  light, — such 
as  would  be  produced  by  the  reflection  of  the 
sun  from  a  window, — or  from  hearing  a  gong 
whose  sound  was  like  that  of  the  one  which 
formerly  had  been  used  for  the  purpose  of 
inducing  hypnosis.  Here,  then,  is  a  true 
lethargic  or  cataleptic  state  which  has  been 
originated  as  a  clinical  artefact,  and  which, 
per  se,  cannot  be  differentiated  from  one  that 
occurs  as  an  actual  manifestation  of  hysteria. 
"When    originating    accidentally   in   the    above 


272  Psychopathology  of  Hysteria 

manner,  these  states  are  comparable  with  the 
anesthesias  of  medical  origin;  both  are  for- 
tuitous manifestations  of  the  increased  sug- 
gestibility that  is  characteristic  of  hysteria. 

When  cataleptic  rigidity  accompanies  morbid 
somnolence  the  condition  is  designated  catalepsy. 
By  means  of  hypnotic  suggestion  cataleptic 
rigidity  can  be  produced  in  almost  all  subjects. 
Given  one  in  whom  a  somnolent  state,  with  or 
without  catalepsy,  has  been  effected  by  this 
means,  it  would  be  impossible  for  a  second  phy- 
sician positively  to  differentiate  the  condition 
itself  from  one  which  had  resulted  as  a  mani- 
festation of  hysteria.  In  fact,  the  trance-like 
states  of  hysteria  in  many  respects  are  auto- 
hypnotic  in  nature. 

An  obstinate  case  of  catalepsy  was  reported 
by  Core.  (Lancet,  June  19,  1909.)  Following 
his  sixth  epileptiform  attack  a  boy  developed 
somnolence  with  muscular  rigidity.  Soon  after 
the  onset  of  this  state  food  that  was  placed  in 
his  mouth  no  longer  was  swallowed,  but  after 
feeding  him  once  through  a  nasal  tube  no  further 
difficulty  was  experienced  in  this  respect.  Gen- 
eral contractures  appeared  after  the  tenth  week. 
During  the  sixteen  weeks  that  the  lethargy  con- 
tinued he  did  not  make  any  voluntary  movements 
except  of  frowning  and  of  withdrawal  from 
painful  stimuli,  and  except  that  his  eyes  re- 
mained open  and  he  watched  the  actions  of  those 
around  him.     Several  times,  too,  he  shouted  dur- 


Alterations  of  Consciousness  273 

ing  galvanization.  Involuntary  urination  was 
persistent.  Without  discoverable  cause  rapid 
recovery  set  in  after  the  condition  had  continued 
sixteen  weeks. 

It  is  interesting  that  cataleptic  states,  like 
psycholepsy  and  many  other  manifestations  of 
hysteria,  are  found  even  among  savages  and  the 
partially  civilized.  In  connection  with  the  epi- 
demic of  religious  hysteria  that  attended  the 
dissemination  of  the  ghost-dance  religion,  Major 
Mac^Iurray  writes  of  the  Indian  Smoholla :  ' '  He 
falls  into  trances  and  lies  rigid  for  considerable 
periods.  Unbelievers  have  experimented  by 
sticking  needles  through  his  flesh,  cutting  him 
with  knives,  and  otherwise  testing  his  sensibility 
to  pain,  without  provoking  any  responsive  action. 
It  was  asserted  that  he  was  surely  dead,  because 
blood  did  not  flow  from  the  wounds."  (Four- 
teenth Annual  Report  of  the  Bureau  of  Eth- 
nology, Smithsonian  Institute,  part  2,  p.  719.) 

Similar  to  the  induction  of  hallucinations  and 
delusions  by  suggestion,  and  also  the  ability  of 
the  subject  to  talk  about  these  experiences  dur- 
ing the  hypnotic  state  or  after  it  has  been  dis- 
pelled, is  the  occurrence  of  like  phenomena  dur- 
ing some  of  the  trance  states  of  hysteria.  As  a 
product  of  the  religious  fervor  of  the  Middle 
Ages,  and  less  frequently  even  at  present, 
hysteria  often  manifested  itself  in  the  produc- 
tion of  what  is  called  ecstasy;  a  state  in  which  a 
deviation  from  the  patient's  usual  state  of  con- 


274  Psychopathology  of  Hysteria 

sciousness  is  accompanied  by  the  occurrence  of 
hallucinatory  revelations  of  a  religious  type. 

Just  as  autosuggestion  is  such  a  powerful 
factor  in  the  genesis  of  individual  sjrmptonis  of 
hysteria,  so  it  is  influential  in  determining  both 
the  onset  of  such  trances  and  the  character  of 
the  revelations.  Consequently,  those  who  ex- 
pected to  be  favored  with  heavenly  revelations 
were  subject  to  delusions  or  hallucinations  of 
this  nature,  while  other  unfortunate  religieuses 
who  believed  that  they  were  possessed,  and  who 
anticipated  intercourse  with  the  devil,  actually 
vociferated  the  occurrence  of  such  proceedings 
during  or  after  their  trances.  As  a  result  of  the 
religious  enlightenment  of  modern  times  ecstasy 
has  disappeared  as  a  religious  phenomenon  only 
to  become  debased  into  being  a  valuable  asset  to 
the  spiritualistic  medium  who  is  enabled,  through 
the  agency  of  autosuggestion,  to  bring  about 
trance-like  states  during  which  she  presumes  to 
reveal  the  future,  consult  with  the  spirit  world, 
and  what  not. 

The  most  wonderful  feature  of  prolonged 
hysteric  somnolence,  is  the  absolute  negativism  of 
a  non-insane  individual  who  passes  what  may  be 
a  great  portion  of  a  life  time  in  what  to  all 
intents  is  an  ideational  sleep.  What  is  more 
remarkable  than  the  extent  of  inhibition  that  is 
exercised  by  such  patients  in  reference  to  the 
countless  ways  in  which  their  condition  may 
affect  loved  ones;  which  renders  them  prisoners 


Alterations  of  Consciousness  275 

upon  a  bed;  which  is  capable  of  reducing  their 
consciousness  to  a  state  that  is  neither  life  nor 
death ;  which  causes  them  to  be  little  better  than 
vegetating  organisms?  Indeed,  the  feats  of 
endurance  and  of  perverse  and  intense  applica- 
tion of  volition  that  are  encountered  in  cases  of 
hysteria  are  more  comprehensible  when  one  con- 
siders the  power  of  morbid  ideation  to  produce 
such  a  state  of  somnolence. 

One  of  the  most  extraordinary  cases  of  pro- 
longed somnolence  is  that  reported  by  Lancer- 
eaux.  (La  Semaine  Med.,  No.  10,  1904.)  The 
somnolence  of  this  patient  developed  with  con- 
vulsions and  general  contractures  after  she  had 
been  subjected  to  intense  emotional  excitement 
at  the  age  of  22  years.  After  having  continued 
twenty  years,  uninterrupted  except  during  con- 
vulsions, the  lethargic  state  disappeared  soon 
before  death  from  phthisis.  With  the  return  of 
consciousness  it  was  found  that  the  patient  was 
amnesic  for  the  whole  period  of  somnolence.  In 
Oettinger's  case  (Jour,  of  Nerv.  and  Ment.  Dis., 
1908,  p.  129)  catheterization  and  enemata  were 
necessary  during  a  third  attack  of  somnolence 
that  lasted  35  days.  Apomorphine  and  pressure 
on  the  supraorbital  nerve  failed  to  arouse  him. 
Five  days  after  the  adoption  of  treatment  with 
cold  baths  the  somnolent  condition  disappeared. 

The  citation  by  Macnish  (The  Philosophy  of 
Sleep,  1840,  p.  245)  of  a  case  of  periodic  morbid 
somnolence  that  presumably  was  due  to  hysteria 


276  Psychopathology  of  Hysteria 

is  interesting  because  of  the  dependence  of  part 
of  the  attacks  upon  the  varying  occurrence, 
in  time,  of  daybreak.  Even  more  interesting 
would  have  been  the  results  of  a  modern  psycho- 
analysis having  as  one  of  its  objects  the  deter- 
mination of  the  cause  of  the  relation  between  the 
attacks  and  daybreak.  "One  of  the  most  extra- 
ordinary instances  of  excessive  sleep, ' '  he  writes, 
''is  that  of  the  Lady  of  Nismes,  published  in 
1777,  in  the  'Memoirs  of  the  Royal  Academy  of 
Sciences  at  Berlin.'  Her  attacks  of  sleep  took 
place  periodically,  at  sunrise  and  about  noon. 
The  first  continued  till  within  a  short  time  of  the 
accession  of  the  second,  and  the  second  till  be- 
tween seven  and  eight  in  the  evening — when  she 
awoke  and  continued  so  till  the  next  sunrise. 
The  most  extraordinary  fact  connected  with  this 
case  is,  that  the  first  attack  commenced  always 
at  daybreak,  whatever  might  be  the  season  of 
the  year,  and  the  other  always  immediately  after 
twelve  o'clock.  During  the  brief  interval  of 
wakefulness  which  ensued  shortly  before  noon, 
she  took  a  little  broth,  which  she  had  only  time 
to  do,  when  the  second  attack  returned  upon 
her,  and  kept  her  asleep  till  the  evening.  Her 
sleep  was  remarkably  profound,  and  had  all  the 
characters  of  complete  insensibility,  with  the 
exception  of  a  feeble  respiration,  and  a  weak  but 
regular  movement  of  the  pulse.  The  most  sin- 
gular fact  connected  with  her  remains  to  be 
mentioned.     When  the  disorder  had  lasted  six 


Alterations  of  Consciousness  277 

months,  and  then  ceased,  she  had  an  interval  of 
perfect  health  for  the  same  length  of  time.  When 
it  lasted  one  year,  the  subsequent  interval  was 
of  equal  duration.  The  affection  at  last  wore 
gradually  away;  and  she  lived,  entirely  free  of 
it,  for  many  years  after.  She  died  in  the  eighty- 
first  year  of  her  age,  of  dropsy,  a  complaint 
which  had  no  connection  with  her  preceding 
disorder. ' ' 

The  recognition  of  cases  of  hysteric  somno- 
lence should  not  be  difficult.  The  stuporous  con- 
dition of  the  patient  is  more  apparent  than  real, 
for  no  matter  how  profound  the  state  may  be 
there  remain  traces  of  awareness  of  environ- 
ment that  can  be  detected  by  close  observation. 
The  closed  eyelids  may  present  a  fine  tremor 
like  the  familiar  one  which  is  seen  when  a 
hysteric  is  told  to  close  her  eyes  during  the 
course  of  a  neurologic  examination. 

The  qualities  of  the  mental  states  which  accom- 
pany hysteric  morbid  somnolence  are  identical 
with  those  of  hj'pnosis ;  with  either  condition  the 
states  are  ones  of  dissociation  that  vary  in  nature 
according  to  the  individual,  and  which  are  char- 
acterized by  inhibition  of  the  conscious  mental 
faculties  with  consequent  emancipation  of  sub- 
consciousness. The  patient  is  not  unconscious; 
she  is  aware  of  her  surroundings  in  the  same 
manner  that  a  case  of  hysteric  amaurosis  per- 
ceives visual  stimuli.  No  matter  how  deep  the 
state  of  apparent  coma  may  seem  the  patient 


278  Psychopathology  of  Hysteria 

hears  and  understands  all  that  is  said  around 
her,  and  for  this  reason  care  must  be  exercised 
in  order  not  to  make  any  remarks  that  one  would 
not  utter  were  the  patient  in  her  usual  condi- 
tion, and  especially  to  avoid  creating  new  mani- 
festations, or  increasing  the  severity  of  those 
already  existing,  by  reason  of  discussing  in  her 
presence  the  symptoms  which  she  has  or  those 
that  might  develop. 

If  we  hypnotize  someone  and  then  remark  to 
a  third  person  that  the  subject's  arm  is  power- 
less, in  most  instances  an  ideational  paralysis 
actually  develops  without  further  suggestion. 
Or,  the  hypnotic  state  can  be  dispelled  by 
making  in  the  same  indirect  manner  the  re- 
mark that  the  subject  is  waking.  To  a  less 
degree  the  same  tendency  exists  in  patients 
with  hysteric  morbid  somnolence.  Instead, 
perhaps,  of  making  indiscreet  remarks  and 
thus  aggravating  the  condition  we  can  take 
advantage  of  this  suggestibility,  and,  by  veil- 
ing our  suggestions,  convey  to  the  patient  ideas 
v/hich  are  favorable  to  recovery,  without,  how- 
ever, allowing  her  to  perceive  that  such  is  our 
intention. 

Just  as  one  who  has  been  hypnotized  may 
or  may  not  remember  the  events  of  the 
hypnotic  state  so  the  memory  of  a  patient  who 
has  recovered  from  hysteric  somnolence  may 
or  may  not  be  deficient.  In  order  to  prove 
that   patients   who   have  recovered  from  leth- 


Alterations  of  Consciousness  279 

argic,  narcoleptic,  and  cataleptic  states,  were 
really  cognizant  of  what  happened  around 
them,  and  in  order  to  demonstrate  that  the 
memories  of  these  occurrences  are  not  lost, 
but  only  dormant,  it  suffices  to  tap  the  pa- 
tient's subconsciousness.  There  are  numer- 
ous methods  of  doing  so.  The  most  important 
of  these  are  hypnotization,  hypnoidization, 
free  association,  reaction  time  experiments,  au- 
tomatic writing,  crystal  vision,  and  suggestion 
in  the  waking  state. 

Let  us  see  what  Janet  has  written  concern- 
ing the  mental  state  during  hysteric  som- 
nolence: ''I  do  not  think  that  in  these  indi- 
viduals the  psychological  phenomena  have  dis- 
appeared; I  do  not  think  that  their  sleep  is  a 
merely  physical  phenomenon.  By  many  methods 
one  can  prove  the  existence  of  thoughts  that 
continue  to  develop  in  their  minds.  First  of 
all,  a  protracted  and  attentive  observation  very 
often  shows  you  slight  signs  connected  with 
thoughts.  There  are  a  few  little  movements 
of  the  lips,  as  if  the  subject  wanted  to  speak, 
or  sometimes  smile,  a  few  little  transient  ex- 
pressions of  the  physiognomy,  a  few  little 
movements  of  the  hands.  In  certain  cases,  you 
have  quite  the  impression  that  the  patient 
chatters  inwardl}^  and  that  but  little  is  wanting 
for  you  to  be  able  to  understand  him.  By 
means  of  certain  processes  which  we  cannot 
study  in  detail,  one  can  sometimes  put  one's 


280  Psychopathology  of  Hysteria 

self  in  relation  with  such  subjects;  by  merely 
touching  them,  speaking  to  them,  it  is  possible 
to  attract  their  attention,  and  then  one  can 
question  them  and  obtain  certain  answers. 
Sometimes,  in  the  most  favorable  cases,  the 
subject  will  answer  by  speaking;  sometimes  he 
will  answer  by  slight  signs  of  the  fingers  or 
face.  If  you  take  his  hand  and  ask  him  to 
press  it  in  order  to  say  'yes,'  sometimes  you 
obtain  nothing  but  movements  of  the  eyelids 
and  eyebrows:  a  slight  lowering  of  the  eye- 
brows will  mean  'yes,'  their  rising  will  mean 
'no.'  And  you  can  thus  penetrate  a  little  into 
his  thought.  Lastly,  in  other  and  more  fre- 
quent cases,  you  will  be  able,  after  the  crisis 
of  sleep,  to  find  again  the  recollection  of  it  in 
states  of  artificially  provoked  somnambulism, 
about  which  I  shall  tell  you  a  few  words  at  the 
end  of  this  lesson. ' ' 

"By  using  these  various  means,  yoii  can 
ascertain  that  the  immobility  of  such  patients 
is  much  less  physical  than  moral.  Some  have 
in  their  mind  the  fixed  idea  of  sleep  or  death, 
and  they  realize  outwardly  the  attitude  they 
are  thinking  of.  But  many  others  have  ideas 
that  are  not  in  the  least  connected  with  the 
sleep.  They  are  seized  with  a  profound  revery, 
in  which  they  contemplate  scenes  that  present 
themselves  before  them,  or  indulge  in  an  end- 
less inward  chattering.  A  girl  of  sixteen,  who 
has  been  terrified  by  a  bull  coming  to  attack 


Alterations  of  Consciousness  281 

her,  has  crises  of  sleep,  with  perfect  immobility, 
during  which  she  is  appalled  by  the  hallucina- 
tion of  the  bull.  Another,  aged  thirty-two,  in 
despair  at  the  death  of  a  friend,  relates  to  her- 
self dismal  stories  about  her  own  death :  '  They 
are  going  to  put  candles  near  my  bed ;  they  are 
putting  me  in  a  little  deal  coffin;  my  friends 
are  bringing  white  flowers  to  put  on  my  little 

coffin,  which  is  there,  placed  on  two  chairs ' 

and  she  talks  thus  endlessly.  A  man  of  twenty- 
five  has  been  much  upset  by  an  accusation 
brought  against  him  by  a  fellow-workman. 
When  he  meets  with  this  individual,  he  be- 
comes motionless,  like  one  petrified,  and  at 
last  he  slips  to  the  ground  and  lies,  as  if  asleep, 
for  hours  together,  talking  inwardly  about  the 
accusation  brought  against  him.  He  fancies  he 
is  before  his  employer,  and  defends  himself  in 
every  way,  arguing  in  a  complicated  manner 
as  if  he  were  before  a  court  of  justice." 
(Major  Symptoms  of  Hysteria,  1906,  p.  106.) 

The  treatment  of  the  various  kinds  of  altera- 
tions of  consciousness  is  the  same  as  that  of 
psych olepsy:  discovery  and  removal  of  the 
psychic  causes  of  the  seizures  and  recovery  of 
dissociated  memories  together  with  fusion  of 
these  with  the  conscious  personality  of  the 
patient. 

Insomnia,  the  opposite  of  morbid  som- 
nolence, is  frequent  in  hysteria.  A  peculiarity 
of  the  human  mind  is  to  exaggerate  the  dura- 


282  Psychopathology  of  Hysteria 

tion  of  interruptions  of  sleep,  or  to  overestimate 
the  length  of  time  before  sleep  appears  after  it 
is  sought.  How  frequent  it  is  to  read  on  the 
nurse's  report:  "Patient  slept  well  the  whole 
night,"  and  then  to  have  the  non-neurotic  pa- 
tient assert  that  he  had  passed  a  sleepless 
night!  Even  more  bitterly  do  psychoneurotics 
complain  of  losing  most  of  their  sleep,  or  of  not 
having  slept  at  all  when,  in  reality,  such  has 
not  been  the  case.  Uncommonly,  the  patient 
actually  does  not  sleep,  but  there  is  sufficient 
mental  and  physical  relaxation  to  prevent  ex- 
haustion, even  though  the  difficulty  may  per- 
sist indefinitely.  In  some  of  these  cases  in- 
somnia is  the  most  prominent,  or  apparently 
even  the  only  symptom  of  the  disease,  and  it 
may  be  resistant  to  treatment.  Usually,  how- 
ever, little  difficulty  is  experienced  in  enabling 
the  patient  to  sleep  in  a  normal  manner. 

Somnambulism. — Without  the  participation 
of  consciousness  psychomotor  activity  that  is 
adapted  to  some  definite  end,  and  which  va- 
ries according  to  environmental  influences,  is 
known  as  somnambulism.  Such  a  definition  is 
most  inclusive:  so  also  has  been  the  use  of  the 
appellation.  The  states  of  massive  dissociation 
induced  by  hypnotic  suggestion  and  which  are 
characterized  by  the  possibility  of  production 
by  suggestion  of  psychomotor  automatism  with 
subsequent  amnesia,  have  been  designated  states 
of  hypnotic  somnambulism.     Sleep  walking  is 


Alterations  of  Consciousness  283 

called  nocturnal,  or  spontaneous,  somnambulism, 
while  various  kinds  of  hysteric  ambulatory  auto- 
matism, whether  nocturnal  or  diurnal,  have  been 
included  under  the  term  hysteric  somnambulism. 
The  distinctiveness  of  the  name  has  been  still 
further  degraded  by  making  it  embrace  the  va- 
rious attacks  of  hysteria.  It  seems  best  to  limit 
the  term  morbid  somnolence  to  a  state  of  disso- 
ciation that  is  manifested  by  a  more  or  less  pro- 
longed sleep-like  condition;  narcolepsy  to  peri- 
odic sleep-like  seizures  of  short  duration;  som- 
nambulism to  a  state  of  dissociation  which  is 
characterized  by  monoideic  psychomotor  auto- 
matism; ambulatory  automatism  and  fugues  to 
more  highly  developed  dissociation  in  which, 
though  the  usual  state  of  consciousness  of  the 
patient  is  in  abeyance,  neither  his  actions  nor 
his  mental  state  may  appear  abnormal  to  stran- 
gers ;  and  multiple  personality  to  the  completely 
developed  type  of  dissociation  that  results  in  the 
production  of  two  or  more  distinct  personalities. 
These  limitations  imply  merely  an  arbitrary 
division  of  a  scale  of  dissociation  whose  intensity 
varies  by  imperceptible  gradations. 

There  is  no  good  reason  why  the  term  noc- 
turnal somnambulism  should  not  include  all 
kinds  of  motor  expression  of  organized  ideation 
that  may  occur  during  sleep,  whether  this  be  by 
walking  or  even  by  talking.  An  individual  is 
not  in  a  state  of  normal  sleep  when  he  gives 
verbal  expression  to  subconscious  ideation.    That 


284  Psychopathology  of  Hysteria 

actual  walking  doesTiot  occur  in  such  cases  may 
be  dependent  merely  upon  the  character  of  the 
underlying  ideation,  and  a  person  who  talks  one 
night  during  sleep  on  another  occasion  may  walk 
around  and  perform  complex  acts  during  the 
same  kind  of  state.  In  the  first  case  he  may 
be  engaged  in  conversation  with  a  hallucinated 
person  and  other  forms  of  activity  may  not  be 
required.  In  the  second  instance  he  is  acting 
logically  in  accordance  with  the  necessity  im- 
posed by  subconscious  ideas  which  happen  to 
arise.  One  of  Macnish  's  cases  of  sleep-walking  is 
a  good  example  of  motor  automatism  dependent 
upon  a  dream:  "I  knew  a  gentleman  who,  in 
consequence  of  dreaming  that  the  home  was 
broken  into  by  thieves,  got  out  of  bed,  dropped 
from  the  window  (fortunately  a  low  one)  into 
the  street ;  and  was  a  considerable  distance  on  his 
way  to  warn  the  police,  Avhen  he  was  discovered 
by  one  of  them,  who  awoke  him,  and  conducted 
him  home."  (The  Philosophy  of  Sleep,  p.  196.) 
It  is  customary  to  speak  of  the  motor  auto- 
matisms of  spontaneous  somnambulism,  but 
each  of  these  is  accompanied  with  sensory  auto- 
matism. Not  only  does  the  sleep-walking  in- 
dividual present  motor  activity,  but  subcon- 
scious sensory  perception  takes  place;  other- 
wise, walking  would  be  impossible  and  the  per- 
formance of  complicated  acts  out  of  the  ques- 
tion. By  reason  of  the  character  of  the  pa- 
tient's utterances  delusions  and  hallucinations 


Alterations  of  Consciousness  285 

are  evident.  Their  existence  and  their  nature 
can  be  proven  through  the  agency  of  psychoan- 
alytic procedures. 

In  the  absence  of  fever,  toxic  states  and  or- 
ganic disease,  persons  who  are  accustomed  to 
exhibit  nocturnal  somnambulism  thereby  dis- 
play so  strong  a  tendency  towards  dissociation 
that  it  seems  reasonable  to  conclude  either  that 
indubitable  evidences  of  hysteria  would  be 
found  were  careful  investigation  instituted,  or 
that  the  disease  otherwise  is  latent.  In  other 
words,  all  well  developed  cases  of  functional 
.spontaneous  somnambulism  are  probably  hys- 
teric in  origin.  As  expressed  by  v.  Bechterew 
{Jour,  of  Abnormal  Psychology,  vol.  1,  p.  25.) 
walking  and  talking  during  sleep  are  manifesta- 
tions which  pass  the  limits  of  the  normal  and 
approach  closely  certain  neurotic  states. 

Clinical  experience  shows  that  but  few  cases 
of  nocturnal  somnambulism  occur  in  the  ab- 
sence of  ob^dous  symptoms  of  hysteria,  and 
that  in  these  exceptions  the  presence  of  exag- 
gerated suggestibility  and  of  emotionalism  is 
decidedly  significant.  Conversely,  with  adult 
hysterics  it  is  exceedingly  common  to  elicit  a 
history  of  repeated  talking  and  walking  during 
sleep.  Just  as  all  symptoms  of  hysteria  are 
probably  only  exaggerations  or  perversions  of 
the  normal,  and  for  the  same  reason  that  all 
states  of  dissociation  are  not  necessarily  patho- 
logic, so  it  would  be  inadvisable  to  regard  as 


286  PsycJiopathology  of  Hysteria 

hysteric  isolated  instances  of  the  utterance  of  a 
few  words  during*  sleep. 

Both  the  mental  states  and  the  phenomena 
that  occur  during  nocturnal  somnambulism  are 
duplicated  by  those  which  arise  spontaneously 
in  the  course  of  some  cases  of  hysteria,  and 
which  are  capable  of  artificial  production  with 
hypnotic  suggestion.  In  each  of  these  condi- 
tions hallucinations  and  systematized  negative 
hallucinations  may  occur.  Personal  perception 
is  limited  to  what  the  ideation  of  the  moment 
necessitates ;  other  perceptions  not  being  syn- 
thetized  with  the  state  of  consciousness  which 
is  uppermost  at  the  time.  Hence  the  ordinary 
somnambulist  does  not  pay  any  attention  to 
those  whom  he  many  encounter,  unless,  in  case 
of  nocturnal  somnambulism  at  least,  their  efforts 
are   suliiciently   strenuous   to    ''awaken"   him. 

Hammond  was  fortunate  enough  to  have  the 
opportunity  of  examining  a  patient  during 
the  course  of  what  evidently  was  an  attack 
of  hysteric  somnambulism,  though  he  does  not 
express  any  opinion  of  its  nature.  '*A  young 
lady,"  he  writes,  "of  great  personal  attrac- 
tions, had  the  misfortune  to  lose  her  mother 
by  death  from  cholera.  Several  other  mem- 
bers of  the  family  suffered  from  the  disease, 
she  alone  escaping,  though  almost  worn  out 
with  fatigue,  excitement,  and  grief.  A  year 
after  these  events,  her  father  removed  from 
the  West  to  New  York,  bringing  her  with  him 


Alterations  of  Consciousness  287 

and  putting  her  at  the  head  of  his  household. 
She  had  not  been  long  in  New  York,  before  she 
became  affected  with  symptoms  resembling  those 
met  with  in  cholera.  The  muscles  of  the  face 
were  in  almost  constant  action,  and  though  she 
had  not  altogether  lost  the  power  to  control 
them  by  her  will,  it  was  difficult  for  her  at 
times  to  do  so.  She  soon  began  to  talk  in 
her  sleep,  and  finally  was  found  one  night 
by  her  father,  as  he  came  home,  endeavoring  to 
open  the  street-door.  She  was  then,  as  he  said, 
sound  asleep,  and  had  to  be  violently  shaken  to 
be  aroused.  After  this  she  made  the  attempt 
every  night  to  get  out  of  bed,  but  was  generally 
prevented  by  a  nurse  who  slept  in  the  same 
room  with  her,  and  who  was  awakened  by  the 
noise  she  made  in  the  room." 

''Her  father  now  consulted  me  in  regard  to 
the  case,  and  invited  me  to  the  house  in  order 
to  witness  the  somnambulic  acts  for  myself.  One 
night,  therefore,  I  went  to  his  residence  and 
waited  for  the  expected  manifestations.  The 
nurse  had  received  orders  not  to  interfere  with 
her  charge  on  this  occasion,  unless  it  was  evi- 
dent that  injury  would  result,  and  to  notify 
us  of  the  beginning  of  the  performance." 

''About  twelve  o'clock  she  came  down  stairs 
and  informed  us  that  the  young  lady  had  risen 
from  her  bed  and  was  about  to  dress  herself. 
I  went  up  stairs,  accompanied  by  her  father, 
and  met  her  in  the  upper  hall  partly  dressed. 


288  Psychopathology  of  Hysteria 

She  was  walking  very  slowly  and  deliberately, 
her  head  elevated,  her  ej^es  open,  her  lips  un- 
closed, and  her  hands  hanging  loosely  by  her 
side.  We  stood  aside  to  let  her  pass.  Without 
noticing  us,  she  descended  the  stairs  to  the 
parlor,  we  following  her.  Taking  a  match, 
which  she  had  brought  with  her  from  her  own 
room,  she  rubbed  it  several  times  on  the  under 
side  of  the  marble  mantelpiece  until  it  caught 
fire,  and  then,  turning  on  the  gas,  lit  it.  She 
next  threw  herself  into  an  armchair  and  look- 
ing fixedly  towards  a  portrait  of  her  mother 
which  hung  over  the  mantelpiece.  While  she 
was  in  this  position,  I  carefully  examined  her 
countenance,  and  performed  several  experi- 
ments with  the  view  of  ascertaining  the  con- 
dition of  the  senses  as  to  activity." 

"She  was  very  pale,  more  so  than  was  natural 
to  her;  her  eyes  were  wide  open  and  did  not 
wink  when  the  hand  was  brought  suddenly  in 
close  proximity  to  them ;  the  muscles  of  the  face, 
which  when  she  was  awake  were  almost  con- 
stantly in  action,  were  now  perfectly  still;  her 
pulse  was  regular  in  rhythm  and  force,  and 
beat  82  per  minute,  and  the  respiration  was  uni- 
form and  slow." 

' '  I  held  a  large  book  between  her  eyes  and  the 
picture  she  was  apparently  looking  at,  so  that 
she  could  not  possibly  see  it.  She  nevertheless 
continued  to  gaze  in  the  same  direction  as  if  no 
obstacle  were  interposed.     I  then  made  several 


Alterations  of  Consciousness  289 

motions  as  if  about  to  strike  her  in  the  face.  She 
made  no  attempt  to  ward  off  the  blows,  nor  did 
she  give  the  slightest  sign  that  she  saw  my 
actions.  I  touched  the  cornea  of  each  eye  with 
a  lead-pencil  I  had  in  my  hand,  but  even  this 
did  not  make  her  close  her  eyelids.  I  was  en- 
tirely satisfied  that  she  did  not  see — at  least  with 
her  eyes." 

"I  held  a  lighted  sulphur-match  under  her 
nose,  so  that  she  could  not  avoid  inhaling  the 
sulphurous  acid  gas  which  escaped.  She  gave 
no  evidence  of  feeling  any  irritation.  Cologne 
and  other  perfumes,  and  smelling-salts  likewise 
failed  to  make  any  obvious  impression  on  her 
olfactory  nerves." 

' '  Through  her  partially  opened  mouth,  I  intro- 
duced a  piece  of  bread  soaked  in  lemon-juice. 
She  evidently  failed  to  perceive  the  sour  taste. 
Another  piece  of  bread,  saturated  with  a  solution 
of  quinine,  was  equally  ineffectual.  The  two 
pieces  of  bread  remained  in  her  mouth  for  a  full 
minute,  and  were  then  chewed  and  swallowed. ' ' 

''She  now  arose  from  her  chair  and  began  to 
pace  the  room  in  an  agitated  manner ;  she  wrung 
her  hands,  sobbed,  and  wept  violently.  While 
she  was  acting  in  this  way,  I  struck  two  books 
together  several  times  so  as  to  make  loud  noises 
close  to  her  ears.     This  failed  to  interrupt  her." 

''I  then  took  her  by  the  hand  and  led  her  back 
to  the  chair  in  which  she  had  previously  been 
sitting.     She  made  no  resistance,  but  sat  down 


290  Psychopathology  of  Hysteria 

quietly  and  soon  became  perfectly  calm.'' 

' '  Scratching  the  back  of  her  hand  with  a  pin, 
pulling  her  hair,  and  pinching  her  face,  appeared 
to  excite  no  sensation." 

"I  then  took  off  her  slippers,  and  tickled  the 
soles  of  her  feet.  She  at  once  drew  them  away, 
but  no  laughter  was  produced.  As  often  as  this 
experiment  was  repeated,  the  feet  were  drawn 
up.     The  spinal  cord  was  therefore  awake. ' ' 

"She  had  now  been  downstairs  about  twenty 
minutes.  Desiring  to  awake  her  I  shook  her  by 
the  shoulders  quite  violently  for  several  seconds, 
without  success.  I  then  took  her  head  between 
my  hands  and  shook  it.  This  proved  effectual  in 
a  little  while.  She  awoke  suddenly,  looked 
around  her  for  an  instant,  as  if  endeavoring  to 
comprehend  her  situation,  and  then  burst  into  a 
fit  of  hysterical  sobbing.  When  she  recovered 
her  equanimity,  she  had  no  recollection  of  any- 
thing that  had  passed,  or  of  having  had  a  dream 
of  any  kind."  (Sleep  and  Its  Derangements, 
1869,  p.  205.) 

The  shock  of  her  mother's  death  was  the  prob- 
able cause  of  this  patient's  condition.  The 
somnambulistic  seizures,  typical  examples  of 
Janet 's  monoideic  somnambulism,  were  evidently 
dependent  upon  a  dissociated  complex  concern- 
ing her  mother. 

During  attacks  of  somnambulism  the  pa- 
tient's attention  is  concentrated  upon  one 
system  of   ideas    to  the  exclusion  of  all  others. 


Alterations  of  Consciousness  291 

When  we  judge  a  somnambulist's  actions  entirely 
as  they  are  adapted  to  the  expression  and  reali- 
zation of  the  one  system  of  ideas  nothing  abnor- 
mal is  noticeable.  Thus  Hammond's  patient 
was  unable  to  perceive  any  stimulus  which  was 
not  related  to  the  death  of  her  mother,  and,  on 
the  other  hand,  when  she  was  left  to  herself,  the 
character  of  her  actions  did  not  differ  mate- 
rially from  those  of  a  person  in  full  possession 
of  consciousness. 

Any  hysteric  trance-like  state  that  is  asso- 
ciated with  monoideic  automatism  may  be  con- 
sidered somnambulistic  whether  it  appears  dur- 
ing the  day  or  if  it  develops  while  the  patient 
has  been  asleep.  As  a  matter  of  fact  even  the 
convulsive  seizures  of  hysteria  are,  as  Janet  has 
contended,  states  of  monoideic,  or,  in  some  cases, 
polyideic  somnambulism;  the  patient  merely  liv- 
ing through  again  some  former  experience. 
Moreover,  convulsive  attacks  may  serve  as  the 
point  of  departure  for  the  elaboration  of  more 
highly  developed  types  of  dissociation  of  con- 
sciousness. 

In  addition  to  psycholeptic  seizures  Sallie  S. 
was  subject  to  occasional  sonmambulistic  attacks. 
During  one  of  these  she  was  taken  by  her  hus- 
band to  the  office  of  their  physician.  While  in 
the  office  she  cried,  and  did  not  appear  to  be 
entirely  conscious  of  her  surroundings.  Indeed, 
she  insisted  that  the  physician  was  unknown  to 
her.     After  returning  home  and  recovering  her 


292  Psychopathology  of  Hysteria 

usual  state  of  consciousness  she  exhibited  amne- 
sia for  the  whole  period  of  the  crisis,  and,  conse- 
quently, she  denied  having  been  out  of  the  house. 
At  no  time  did  she  believe  either  her  husband  or 
her  physician  when  they  related  what  had  really 
occurred.  While  in  the  hypnotic  state  she  re- 
membered all  the  events  of  her  crisis.  It  appears 
that  the  seizure  was  consequent  upon  a  state  of 
profound  meditation  concerning  the  illness  and 
death  of  her  first  child,  and  the  crying  repre- 
sented her  grief  on  this  occasion.  Her  attention 
being  concentrated  upon  these  painful  memories 
she  was  oblivious  to  most  extraneous  perceptions 
and  ideas. 

The  lack  of  recognition  of  environment  ex- 
hibited by  somnambulistic  patients  is  similar  to 
the  normal  deficiency  of  conscious  recognition  of 
what  is  perceived  but  not  attended  to  when  one 
has  his  attention  deeply  concentrated. 

Ambulatory  Automatism  and  Fugues.  The 
more  complete  the  dissociation  of  consciousness, 
the  more  closely  do  the  resultant  mental  states 
and  their  physical  expression  resemble  normal 
standards.  When  a  person  is  actuated  by  one 
idea  to  the  exclusion  of  all  others,  his  manner 
of  reacting  to  environment  is  necessarily  defec- 
tive. Whereas,  the  greater  the  amount  of 
cleavage,  the  better  the  foundation  with  which 
to  enter  into  external  relations.  A  necessary 
corollary  is  that  the  less  the  amount  of  dissocia- 
tion the  more  numerous  must  be  hallucinations, 


Alterations  of  Consciousness  293 

and  particularly  ''negative  hallucinations." 
Following  the  terminology  of  Janet,  let  us  apply 
the  designation  polyideic  somnambulism  to  cases 
presenting  automatisms  dependent  upon  the 
cleavage  of  more  than  one  system  of  memories. 
With  almost  imperceptible  gradations,  cases 
might  be  adduced  beginning  with  monoideic 
somnambulism  and  ascending  the  scale  of  disso- 
ciation to  attain  the  most  highly  evolved  type 
of  the  affection — multiple  personality.  Hand  in 
hand  with  the  evolution  of  dissociation,  or  the 
development  of  parasitic  and  independent  per- 
sonalities, is  the  approach  towards  the  normal 
of  the  reactions  of  the  individual.  Polyideic 
somnambulism,  then,  is  characterized  by  adapta- 
bility to  environment  that  is  far  greater  than 
that  of  the  monoideic  variety. 

The  case  of  Mr.  X.,  which  was  mentioned  in 
the  section  dealing  with  asthma,  was  compli- 
cated by  an  interesting  type  of  somnambulism 
whose  recurrences  were  discovered  to  have 
been  provoked  by  association  of  ideas,  and 
whose  origin  was  not  as  incomprehensible  as 
at  first  one  would  believe.  The  case  illustrates, 
also,  the  gradual  evolution  of  a  highly  devel- 
oped form  of  polyideic  somnambulism — one 
which  approached  closely  veritable  multiple 
personality — from  what  was  originally  a  simple 
type  of  monoideic  somnambulism.  In  order  to 
describe  these  manifestations  allow  me  to  quote 
some  selected  paragraphs  from  the  original  re- 


294  Psychopathology  of  Hysteria 

port:  ^'Prolonged  attacks  of  coughing,  termi- 
nating with  the  expectoration  of  glairy  mucus 
and  the  immediate  onset  of  a  trance-like  state 
that  lasted  from  fifteen  minutes  to  three  hours, 
first  appeared  in  1905.  It  was  noticed  that  these 
seizures,  occurring  about  ten  times  annually, 
were  always  induced  by  excitement  or  mental 
stress.  Often  he  walked  around  during  the 
somnambulistic  stage,  guiding  himself  by 
tactual  perceptions,  but  he  seemed  to  pay  no  at- 
tention to  what  happened,  save  that  he  occa- 
sionally answered  questions.  Though  his  eyes 
usually  remained  open  and  fixed  he  never  ap- 
peared to  see  anything.  He  was  often  observed 
passing  his  fingers  over  the  crystal  of  his 
watch;  and  if  the  time  of  one  of  his  engage- 
ments was  approaching,  as  determined  by  him 
in  this  manner,  he  was  usually  able  to  bring 
about  reversion  to  the  personality  normal  to 
him.*  At  the  termination  of  one  of  these  ab- 
normal states  of  consciousness  he  would  be  be- 
wildered for  a  short  time  and  was  never  able  to 


♦Believing  that  the  watch  was  superfluous  and  that 
his  ability  to  recognize  the  time  was  dependent  upon 
subconscious  registration  of  the  passage  of  time,  Mr.  X. 
w^as  tested  with  a  watch  which  he  knew  had  been  set 
incorrectly.  He  was  unable  to  detect  the  position  of 
the  hands  when  tested  in  this  manner,  yet,  a  few  min- 
utes before,  he  had  given  out  the  time  within  three 
minutes  of  being  correct,  even  though  the  watch  which 
he  had  palpated  had  been  concealed  from  his  view, 
there  was  not  any  clock  in  the  room,  and  he  had  not 
seen  a  watch,  or  clock,  for  at  least  three  quarters  of 
an  hour.  This  ability  subconsciously  to  recognize  the 
passage  of  time  is  the  means  by  which  some  fortunate 
individuals  are  able  to  waken  at  whatever  time  they 
desired  before  going  to  sleep. 


Alterations  of  Consciousness  295 

remember  what  had  occurred  during  their  con- 
tinuance. ' ' 

"In  addition  to  the  type  of  seizure  just  de- 
scribed a  variation  developed  in  1906.  Follow- 
ing an  emotional  shock,  worry,  or  an  excessive 
amount  of  the  mental  application  incidental  to 
the  pursuit  of  his  profession,  a  severe  paroxysm 
of  coughing  might  appear,  succeeded  by  a 
stuporous  condition  lasting  from  one  to  fifteen 
minutes.  After  the  cessation  of  this  latter 
state  he  became  very  loquacious,  holding  tele- 
phonic' conversations  in  which  he  talked  of  his 
business  affairs.  Though  he  paid  no  attention  to 
his  surroundings  he  occasionally  answered, 
relevantly  or  not,  questions  that  were  addressed 
to  him.  The  fact  that  he  is  known  to  have  dis- 
played resistance  to  passive  movements,  to- 
gether with  other  evidences  of  opposition,  would 
tend  to  indicate  the  presence  of  negativism  on 
these  occasions.  During  one  of  these  states  of 
dissociation  he  defeated  Dr.  Kulp  at  a  game  of 
chess  in  which  he  followed  the  plays  only  by 
tactual  perceptions.  In  the  course  of  the  two 
years  previous  to  the  employment  of  hypnotic 
methods  of  treatment,  about  twelve  attacks  of 
this  type  occurred,  each  of  which  was  followed 
by  amnesia  localized  to  the  period  of  disso- 
ciation. ' ' 

''Early  in  the  year  1908  Dr.  Kulp,  in  order 
to  treat  locally  an  obstinate  inflammation  of 
the    nasopharynx,    passed    into    the    patient's 


296  Psychopathology  of  Hysteria 

posterior  nares  an  applicator  on  which  was 
some  cotton  saturated  with  a  solution  of  iodine 
in  glycerine.  At  once  there  appeared  prolonged 
and  severe  coughing  which  terminated  in  a 
somnambulistic  condition  similar  in  nature  to 
those  already  described.  The  possibility  of 
this  sequence  being  merely  coincidental  was 
eliminated  by  ascertaining  that  it  occurred 
whenever  an  applicator  was  passed  into  the 
posterior  nares,  even  though  no  solutions  were 
employed.  After  determining  this  causality 
the  applications  were  of  necessity  discontinued. ' ' 

''June  4,  1908,  the  patient,  after  having  lost 
much  sleep  from  coughing  during  the  previous 
night  left  home  at  9.30  a.  m.  He  was  after- 
wards informed  that  when  he  entered  his  office 
he  acted  and  talked  strangely  for  a  short  time 
prior  to  going  into  his  private  room,  where  he 
was  found  asleep  at  2  p.  m.  Upon  being 
awakened  at  this  time  he  was  in  his  usual  state 
of  consciousness  and  knew  nothing  of  what  had 
occurred  following  his  departure  from  home. 
While  out  for  lunch,  and  without  having  had 
any  emotional  provocation  or  precursory  attack 
of  coughing  of  which  he  was  afterwards  con- 
sciously aware,  the  secondary  state  again  de- 
veloped and  continued  until  his  return  to  the 
office  at  about  4  p.  m.  He  was  never  able  to 
find  out  the  nature  of  his  actions  during  this 
second  attack  of  ambulatory  automatism.'^ 

"Alarmed  by  these  happenings  he  went  home 


Alterations  of  Consciousness  297 

and  slept  until  6  p.  m.,  when  he  woke  up  in  the 
secondary  state.  At  his  lodge,  in  the  evening, 
he  talked  in  a  sensible  manner  to  the  secretary 
about  matters  of  importance,  and  then  con- 
ferred a  degree  upon  some  of  the  members. 
Later,  some  of  his  friends  noticed  something 
peculiar  in  his  condition  and  advised  him  to  go 
home.  Thereupon  he  walked  home,  and  his 
wife  afterwards  reported  that  upon  going  to 
bed  he  had  an  attack  of  cougliing,  followed  by 
one  of  his  somnambulistic  states  of  loquacious- 
ness which  lasted  for  two  hours.  The  next 
day,  being  in  his  usual  state,  he  was  unable  to 
remember  anything  which  had  happened  the 
previous  evening  except  the  little  he  acquired 
through  isolated  memory  flashes." 

"For  the  purpose  of  causing  a  somnambulis- 
tic attack  an  application  was  made  to  his 
posterior  nares.  There  appeared  immediately 
a  violent  paroxysm  of  uninterrupted  coughing, 
similar  to  that  of  pertussis,  associated  with 
clonic  movements,  almost  epileptic  in  nature, 
of  the  arms.  In  the  efforts  of  coughing 
the  patient  flexed  his  body  extremely  and 
appeared  to  contract  every  voluntary  muscle. 
After  coughing  about  fifty  times  he  became  ex- 
hausted, and  the  cough  ceased.  Sitting  with 
his  head  in  his  hands,  his  breathing  became 
deeper,  and  Cheyne-Stokes  type  of  respiration 
appeared,  followed,  a  coupJe  of  minutes  after 
the  last  cough,  by  the  onset  of  unconsciousness. 


298  Psychopathology  of  Hysteria 

My  attempt  at  experimentation  having  as  its 
end  the  determination  of  the  character  of  his 
state,  caused,  or  was  coincidental  with  the  re- 
turn of  consciousness.  On  account  of  his  great 
exhaustion  it  was  deemed  inadvisable  to  cause 
a  recurrence  of  the  paroxysm;  consequently  T 
was  unable  to  demonstrate  experimentally  the 
auto-hypnotic  nature  of  the  final  stage." 

"During  the  same  evening  he  was  readily 
hypnotized,  for  the  first  time,  in  about  one 
minute.  After  T  had  made  the  suggestion  that 
he  should  'awaken,^  about  a  half  hour  later, 
his  first  question  was:  'When  are  you  going  to 
begin?'  The  artificial  hypnotic  dissociation 
was  so  complete  that  he  was  not  aware  of  hav- 
ing been  hypnotized;  though,  by  reason  of  his 
amnesia  for  all  the  suggestions  that  had  been 
made,  it  was  apparent  that  the  hypnotic  state 
had  actually  been  produced." 

"While  he  was  in  the  hypnotic  state,  during 
his  third  visit — November  23,  1908 — an  effort 
was  made  to  determine  the  causes,  of  which  he 
was  consciously'  unaware,  of  his  manifestations, 
with  the  following  result:  Being  frequently 
awakened  from  a  sound  sleep  by  the  onset  of  an 
attack  of  asthma,  he  acquired  the  habit  of  resort- 
ing to  the  inhalation  of  fumes  from  a  burning 
asthma  powder,  while  sitting  on  the  side  of  the 
bed  with  his  head  in  his  hands.  The  fumes  irri- 
tated his  larynx  and  this,  in  addition  to  the  usual 
postasthmatic  tendency  to   cough,  produced   a 


Alterations  of  Consciousness  299 

severe  paroxysm  of  coughing.  The  great  ex- 
haustion following  the  paroxysm,  together  with 
the  soothing  effects  of  relief  from  dyspnoea  and 
the  natural  tendency  to  fall  asleep  again  after 
having  been  awakened  in  the  middle  of  the  night, 
caused  him  to  fall  asleep  while  sitting  there  with 
his  head  in  his  hands.  The  repetition  of  this 
sequence,  almost  every  night,  soon  resulted  in  the 
formation  of  a  number  of  powerful  associations, 
and  there  appeared  gradually  a  tendency  to  fall 
asleep  during  the  day,  after  the  use  of  his  asthma 
powders.  This  experience  having  occurred 
many  times  a  psychic  short  cut,  like  those  found 
so  often  in  the  study  of  the  mechanism  of 
hysteric  accidents,  became  established,  and  the 
more  highly  elaborated  auto-hypnotic  or  som- 
nambulistic condition  began  to  appear  following 
a  severe  cough  even  without  the  asthma  powder 
having  been  used. ' ' 

"The  local  irritation  caused  by  the  appli- 
cation to  his  posterior  nares  resembled  the  irri- 
tation due  to  inhalation  of  the  fumes  of  his 
asthma  powder;  the  paroxysm  of  coughing  and 
its  consequences  was  therefore  the  result  of  asso- 
ciation of  ideas.'' 

*'The  beneficial  results  of  suggestion  during 
the  hypnotic  state  become  apparent  immediately 
following  his  first  treatment.  During  his  second 
visit  he  asserted  that  he  had  slept  deeply  three 
nights  out  of  five  without  having  been  awakened 
by  an  attack  of  asthma.     In  addition  to   this 


300  Psychopathology  of  Hysteria 

unusual  state  of  affairs  he  was  able  to  sleep  with 
one  pillow  less  under  his  head. ' ' 

"While  under  hypnosis  the  second  time,  the 
suggestion  was  made,  among  others,  that  par- 
oxysms of  coughing  and  somnambulistic  at- 
tacks would  never  occur  again  following  appli- 
cations to  his  posterior  nares.  After  being 
aroused  from  the  hypnotic  state  he  was  told  that 
an  application  was  to  be  made.  Not  being  con- 
sciously aware  of  any  of  the  suggestions  that  had 
been  made,  he  prepared  for  the  usual  conse- 
quences. Much  to  his  surprise  there  occurred 
nothing  but  a  few  coughs." 

"Since  Mr.  X.  first  came  under  my  care  — 
November  13,  1908  —  he  has  been  hypnotized 
only  eight  times.  At  present  he  sleeps  well 
without  being  awakened  by  asthmatic  attacks, 
and  instead  of  having  paroxysms  of  coughing 
when  he  arises  in  the  morning,  only  a  few  coughs 
occur.  In  fact  he  now  has  no  paroxysms  w^hat- 
ever,  and  since  his  first  treatment  he  has  not  had 
a  single  one  of  any  of  his  various  somnambulistic 
attacks. ' '  (Jour,  of  Abnormal  Psychology,  Aug. 
—  Sept.,  1909.) 

Somewhat  similar  to  one  of  the  exciting  causes 
of  the  attacks  of  Mr.  X.  was  one  of  those  of  a 
case  briefly  mentioned  by  Gowers;  the  patient 
all  of  his  life  being  subject  to  narcoleptic  attacks 
whose  exciting  causes  included  the  passage  of  a 
probe  into  a  nasal  fistula. 

During    highly    elaborated     somnambulistic 


Alternations  of  Consciousness  301 

states  hysteric  patients  occasionally  run  away 
from  home.  Such  flights — designated  fugues, 
or  ambulatory  automatism — are  the  realization 
of  former  vague  desires.  Long  continued  vol- 
untary suppression  of  unfulfilled  desire  leads 
to  dissociation  of  a  complex  of  which  it  is  the 
nucleus.  If  a  massive  dissociation  should  occur 
at  any  time  this  complex  would  tend  to  as- 
sume activity  that  had  for  its  end  accomplish- 
ment of  the  old  longing;  whether  this  be  crav- 
ing for  travel  for  its  own  sake,  or  simply  desire 
to  rim  away  as  a  pusillanimous  means  of  es- 
cape from  relatively  great  responsibilities  and 
difficulties. 

When  the  ordinary  annoyances  of  home  life 
become  too  overwhelming  for  the  sensitive  and 
incompetent  hysteric  to  sustain,  the  thought  of 
escape  from  these  tribulations  naturally  must 
arise.  As  the  hysteric  is  impulsive — as  he  tends 
without  critical,  conscious  reflection  to  act  upon 
ideas  as  they  arise — the  thought  of  evasion  acts 
with  all  the  force  that  autosuggestion  is  ca- 
pable of  exerting  in  this  disease.  Finally,  as 
the  consequence  of  a  relatively  severe  stress, 
or,  in  fact,  even  of  a  minor  one  that  serves  as 
the  last  straw,  a  superior  kind  of  somnambulis- 
tic condition  develops,  and  in  response  to  an 
irresistible  and  unquestioned  impulse  the  flight 
is  accomplished.  As  judged  by  ordinary  stan- 
dards the  fugue  of  hysteria  is  irrational  in 
that  the  manifestation  is  out  of  all  proportion 
to  the  provocation. 


302  Psychopathology  of  Hysteria 

Fugues  are  attended  by  a  distinct  alteration 
in  the  personality  of  the  patient;  his  habits, 
temperament,  likes  and  dislikes,  and  even  his 
name  becoming  changed.  Just  as  during  hys- 
teric attacks  the  actions  and  verbal  utterances 
reflect  the  delusions  and  hallucinations  of  the 
patient,  so  the  conduct  during  fugues  is  that 
which  is  natural  to  the  patient,  but  which  for- 
merly had  been  suppressed  in  the  attempt  to 
conform  to  the  restraints  of  home  life  and  to 
the  manners  and  customs  imposed  by  civiliza- 
tion and  environment. 

Though  his  past  life  may  be  forgotten — i.  e. 
the  memories  are  incapable  of  volitional  re- 
production during  the  existence  of  the  new 
personality — yet  isolated  memories  at  times 
arise  above  the  level  of  his  new  state  of  con- 
sciousness, and,  therefore,  his  actions  are  not 
those  of  one  who  really  has  had  all  the  mem- 
ories of  his  preceding  life  blotted  out.  In  ad- 
dition to  these  memory  flashes  what  may  be 
called  general  knowledge  usually  is  common 
to  both  states.  It  is  by  reason  of  these  legacies 
from  his  former  life  that  he  is  enabled  to  con- 
duct himself  in  a  manner  that  does  not  seem 
peculiar,  or  abnormal,  to  those  with  whom  he 
comes  into  contact;  otherwise,  soon  he  would 
be  committed  to  jail,  or  a  hospital.  But,  as  a 
considerable  portion  of  his  memories  are  sub- 
merged the  new  state  must  be  distinctly  in- 
ferior to  the  old  one.     In  describing  the  sec- 


Alterations  of  Consciousness  303 

ondary  state  of  Ansel  Bourne,  Professor  James 
characterizes  it  as  a  "rather  shrunken,  de- 
jected, and  amnesic  extract  of  Mr.  Bourne 
himself." 

Inasmuch  as  the  specific  memories  pertain- 
ing to  the  patient's  usual  personality  and  those 
of  his  state  of  consciousness  during  a  fugue  are 
mutually  incompatible  he  is  not  cognizant  in 
either  state  of  the  personal  memories  of  the 
other.  This  is  readily  comprehended  when  we 
consider  that  often  the  patient  had  been  sub- 
duing for  many  months  or  years  the  vague  de- 
sire to  escape  from  troubles,  for  the  reason  that 
in  his  usual  state  a  flight  would  have  been 
looked  upon  as  cowardly  and  despicable,  had 
he  permitted  himself  seriously  to  contemplate 
this  procedure.  Consequently,  when  the  state 
of  massive  dissociation  develops,  and  the  fugue 
becomes  a  fact,  he  knows  neither  why  he  is 
running  away,  nor  even  that  he  is  doing  so. 

Besides  those  occurring  as  manifestations  of 
hysteria,  fugues  are  believed  to  result  less  fre- 
quently from  trauma,  alcoholic  and  other  toxic 
states,  degeneracy,  and  epilepsy.  In  most  of 
the  cases  which  follow  trauma  the  injury  acts 
only  as  an  exciting  cause,  and  the  fugue  itself 
is  hysteric  in  character  just  as  the  post- 
traumatic paralysis  that  is  encountered  so  fre- 
quently in  hysteria  is  usually  a  psychic  paraly- 
sis, and  not  one  which  is  a  direct  consequence 
of  actual  injury  to  the  part.     The   fugues  of 


304  Psychopathology  of  Hysteria 

degeneracy  differ  from  those  of  hysteria  in  that 
the  flight  is  not  accompanied  by  an  altered  state 
of  consciousness,  and  like  the  psychasthenic 
fugne,  for  several  days  or  more  before  leaving 
home  the  patient  may  feel  the  growth  of  the 
impulsion  to  run  away,  and,  accordingly, 
preparations  even  may  be  made  for  the  "get 
away."  The  fugue  of  either  of  these  conditions 
is  voluntary  or  semi-voluntary,  while  that  of 
hysteria,  on  the  other  hand,  occurs  suddenly 
without  any  conscious  preparations,  is  effected 
during  a  deviation  from  the  usual  state  of  con- 
sciousness of  the  patient,  and  is  followed  by 
amnesia  for  the  whole  period  of  its  existence. 

As  the  record  of  an  actual  case  is  far  more 
valuable  than  pages  of  generalizations  allow 
me  to  quote  William  James'  well  known  Ansel 
Bourne  case  of  ambulatory  automatism  and 
then  one  of  my  own  cases  illustrating  the  fugue 
of  degeneracy: 

"The  Rev.  Ansel  Bourne,  of  Greene,  R.  I., 
was  brought  up  to  the  trade  of  a  carpenter; 
but,  in  consequence  of  a  sudden  temporary  loss 
of  sight  and  hearing  under  very  peculiar  cir- 
cumstances, he  became  converted  from  Atheism 
to  Christianity  just  before  his  thirtieth  year, 
and  has  since  that  time  for  the  most  part  lived 
the  life  of  an  itinerant  preacher.  He  has  been 
subject  to  headaches  and  temporary  fits  of  de- 
pression of  spirits  during  most  of  his  life,  and 
has  had  a  few  fits   of  unconsciousness   lasting 


Alterations  of  Consciousness  305 

an  hour  or  less.  He  also  has  a  region  of 
somewhat  diminished  cutaneous  sensibility  on 
the  left  thigh.  Otherwise  his  health  is  good, 
and  his  muscular  strength  and  endurance  ex- 
cellent. He  is  of  a  firm  and  self-reliant  disposi- 
tion, a  man  whose  yea  is  yea  and  his  nay,  nay; 
and  his  character  for  uprightness  is  such  in  the 
community  that  no  person  who  knows  him  will 
for  a  moment  admit  the  possibility  of  his  case 
not  being  genuine." 

"On  January  17,  1887,  he  drew  551  dollars 
from  a  bank  in  Providence  with  which  to  pay 
for  a  certain  lot  of  land  in  Greene,  paid  certain 
bills,  and  got  into  a  Pawtucket  horse  car.  This 
is  the  last  incident  which  he  remembers.  He 
did  not  return  home  that  day  and  nothing  was 
heard  of  him  for  two  months.  He  was  pub- 
lished in  the  papers  as  missing,  and  foul  play 
being  suspected,  the  police  sought  in  vain  his 
whereabouts.  On  the  morning  of  March  14. 
however,  at  Norristown,  Pennsylvania,  a  man 
calling  himself  A.  J.  Brown,  who  had  rented  a 
small  shop  six  weeks  previously,  stocked  it  with 
stationery,  confectionery,  fruit  and  small  articles, 
and  carried  on  his  quiet  trade  without  seeming  to 
any  one  unnatural  or  eccentric,  woke  up  in  a 
fright  and  called  in  the  people  of  the  house  to 
tell  him  where  he  was.  He  said  that  his  name  was 
Ansel  Bourne,  that  he  was  entirely  ignorant  of 
Norristown,  that  he  knew  nothing  of  shop-keep- 
ing, and  that  the  last  thing  he  remembered — it 


306  Psychopathology  of  Hysteria 

seemed  only  yesterday — wavS  drawing  the  money 
from  the  hank,  etc.,  in  Providence.  He  would 
not  helieve  that  two  months  had  elapsed.  The 
people  of  the  house  thought  him  insane ;  and  so, 
at  first,  did  Dr.  Louis  H.  Read,  whom  they  called 
in  to  see  him.  But  on  telegraphing  to  Prov- 
idence, confirmatory  messages  came,  and  pres- 
ently his  nephew,  Mr.  Andrew  Harris,  arrived 
upon  the  scene,  made  everything  straight,  and 
took  him  home.  He  was  very  weak,  having 
lost  apparently  over  twenty  pounds  of  flesh 
during  his  escapade,  and  had  such  a  horror  of 
the  idea  of  the  candy-store  that  he  refused  to 
set  foot  in  it  again." 

"The  first  two  weeks  of  the  period  remained 
unaccounted  for,  as  he  had  no  memory,  after 
he  had  once  resumed  his  normal  personality,  of 
any  part  of  the  time,  and  no  one  who  knew  him 
seems  to  have  seen  him  after  he  left  home.  The 
remarkable  part  of  the  change  is,  of  course,  the 
peculiar  occupation  which  the  so-called  Brown 
indulged  in.  Mr.  Bourne  had  never  in  his  life 
had  the  slightest  contact  with  trade.  'Brown' 
was  described  by  the  neighbors  as  taciturn, 
orderly  in  his  habits,  and  in  no  way  queer.  He 
went  to  Philadelphia  several  times;  replenished 
his  stock ;  cooked  for  himself  in  the  back  shop, 
where  he  also  slept;  went  regularly  to  church; 
and  once  at  a  prayer-meeting  made  what  was 
considered  by  the  hearers  a  good  address,  in 
the   course    of  which   he   related   an   incident 


Alternations  of  Consciousness  307 

which  he  had  witnessed  in  his  natural  state  of 
Bourne." 

"This  was  all  that  was  known  of  the  case  up 
to  June  1890,  when  I  induced  Mr.  Bourne  to 
submit  to  hypnotism,  so  as  to  see  whether, 
in  the  hypnotic  trance,  his  'Brown'  memory 
would  not  come  back.  It  did  so  with  surpris- 
ing readiness ;  so  much  so  indeed  that  it  proved 
quite  impossible  to  make  him  whilst  in  the  hyp- 
nosis remember  any  of  the  facts  of  his  normal 
life.  He  had  heard  of  Ansel  Bourne,  but 
*  didn't  know  as  he  had  ever  met  the  man.' 
When  confronted  with  Mrs.  Bourne  he  said  that 
he  had  'never  seen  the  woman  before,'  etc.  On 
the  other  hand,  he  told  of  his  peregrinations 
during  the  lost  fortnight,  and  gave  all  sorts  of 
details  about  the  Norristown  episode.  The  whole 
thing  was  prosaic  enough;  and  the  Brown-per- 
sonality seems  to  be  nothing  but  a  rather 
shrunken,  dejected,  and  amnesic  extract  of 
Mr.  Bourne  himself.  He  gave  no  motive  for 
the  wandering  except  that  there  was  'trouble 
back  there'  and  he  'wanted  rest.'  During  the 
trance  he  looks  old,  the  corners  of  his  mouth 
are  drawn  down,  his  voice  is  slow  and  weak, 
and  he  sits  screening  his  eyes  and  trying  vainly 
to  remember  what  lay  before  and  after  the  two 
months  of  the  Brown  experience.  'I'm  all 
hedged  in,'  he  says:  'I  can't  get  out  at  either 
end.  I  don't  know  what  set  me  down  in  that 
Pawtucket  horse-car,  and  I  don't  know  how  T 


308  Psychopathology  of  Hysteria 

ever  left  that  store,  or  what  became  of  it.'  His 
eyes  are  practically  normal,  and  all  his  sensi- 
bilities (save  for  tardier  response)  about  the 
same  in  hypnosis  as  in  waking.  I  had  hoped 
by  suggestion,  etc.,  to  run  the  two  person- 
alities into  one,  and  make  the  memories  con- 
tinuous, but  no  artifice  would  avail  to  accom- 
plish this,  and  Mr.  Bourne's  skull  to-day  still 
covers  two  distinct  personal  selves."  (The 
Principles  of  Psychology,  vol.  1,  p.  391,  1905.) 

A  psychasthenic  boy  of  17  years  had  had 
about  twenty  fugues.  The  first  of  these  oc- 
curred in  his  eleventh  year  and  followed  a 
quarrel  with  his  aunt,  who  accused  him  of  steal- 
ing some  money  from  her.  The  flight,  he  stated, 
was  accomplished  of  his  own  free  will.  He  re 
mained  away  about  one  week  before  being  dis- 
covered by  the  police  and  sent  home.  During 
the  week  he  had  walked  the  streets  looking  for 
work,  and  at  night  he  slept  in  wagons  and 
stables.  The  second  flight  took  place  one  week 
after  his  return  from  the  first  one.  Having  run 
away  eight  times  in  the  space  of  one  year  he 
was  sent  to  a  state  institution  where  he  re- 
mained nineteen  months.  Later  he  was  con- 
fined eight  months  in  the  same  institution.  Of 
the  large  number  of  his  fugues  he  was  brought 
back  by  the  police  in  all  but  two,  whose  ter- 
mination was  effected  by  a  sudden  and  ap- 
parently causeless  desire  to  return  home.  The 
only  time  that  he  stole  was  to  obtain  money 


Alterations  of  Consciousness  309 

for  a  flight,  and  his  thefts  were  limited  to  mem- 
bers of  his  family.  Several  days  before  each 
fugue  he  became  irritable  and  moody.  The 
first  one  was  entirely  voluntary,  he  stated,  while 
the  others  resulted  from  impulses  which  he 
could  not  resist,  though  he  did  not  exert  him- 
self much  to  do  so.  Through  the  agency  of 
hypnotic  suggestion  all  of  his  many  psychasthe- 
nic symptoms  disappeared,  but,  after  the  fourth 
treatment,  he  failed  to  return,  and  several 
weeks  later  he  had  a  fugue  which  continued  for 
five  weeks. 

The  last  fugue  before  coming  under  my  care 
illustrates  the  voluntary,  or  semi-voluntary, 
nature  of  those  due  to  degeneracy.  Several  days 
before  the  evasion  he  accidentally  discovered 
some  money  belonging  to  his  father.  On  aris- 
ing several  mornings  later  he  was  conscious  of 
an  impulsion,  which  he  tried  to  suppress,  to 
run  away.  Just  before  going  to  work  he  ap- 
propriated the  money  which  he  had  found  and 
then  boarded  a  trolley  that  went  past  the  shop 
where  he  was  employed.  While  in  the  car 
something  said  to  him,  as  he  expressed  it,  ''Now 
is  your  chance."  Acting  on  this  impulse  he  re- 
mained in  the  car  and  went  to  a  city  thirty 
miles  distant.  About  a  week  later  he  felt  that 
he  w^as  not  acting  right  so  he  returned  home. 

Formerly,  all  fugues  were  supposed  to  be 
manifestations  of  epilepsy,  and,  as  such,  they 
were  designated  psychic  epilepsy.     Gradually 


310  Psychopathology  of  Hysteria 

the  tendency  has  been  evolved  to  ascribe  to 
epilepsy  but  few  of  the  cases,  and  some  au- 
thorities deny  that  the  different  phenomena 
v/nich  are  included  under  this  term  have  any 
other  relation  to  epilepsy  than  through  their 
superficial  resemblance  to  certain  features  of 
this  disease.  Among  others  who  have  enlisted 
modern  psychoanalytic  methods  in  their  in- 
vestigations of  psychic  epilepsy,  Sidis  denies 
that  epilepsy  has  any  influence  in  the  causation 
of  these  alterations  of  consciousness.  He 
classifies  as  recurrent  psychomotor  states  of  dis- 
sociation all  of  the  cases  known  as  psychic 
epilepsy,  or  those  exhibiting  ''psychic  equiv- 
alents" of  an  epileptic  attack.  Rigid  analysis 
of  such  cases,  he  states,  shows  that  they  have 
nothing  to  do  with  epilepsy  even  though  they 
may  be  found  in  association  with  this  disease. 
(Boston  Med.  and  Surg.  Jour.,  Mar.  14,  1907.) 

As  hysteria  and  epilepsy  often  coexist  ver- 
itable fugues  may  occur  in  patients  who  are 
subject  to  indubitable  epileptic  convulsions 
without,  however,  signifying  that  both  manifes- 
tations are  epileptic  in  origin. 

Like  the  fact  that  on  the  basis  of  the  seizure 
itself  it  is  impossible  to  differentiate  many  cases 
of  hysteric  psycholepsy  from  epileptic  convul- 
sions, it  has  been  shown  by  J.  W.  Courtney  that 
the  supposed  differential  signs  between  the 
fugues  of  hysteria  and  those  of  epilepsy  are 
fallacious.    He    concluded    that    an    epileptic 


Alterations  of  Consciousness  311 

fugue  per  se  does  not  possess  any  peculiarities 
which  distinguish  it  from  many  of  the  flights 
of  hysteria,  and  for  this  reason  the  diagnosis 
between  the  two  conditions  should  not  be  at- 
tempted on  the  characteristics  of  the  fugue 
alone.  (Jour,  of  Abnormal  Psych.,  vol.  1,  p. 
123.)  In  an  exhaustive  paper  on  ambulatory 
automatism  Patrick  writes :  "  I  do  not  wish  to 
be  understood  as  doubting  the  existence  of 
epileptic  wandering.  Unequivocal  cases  are 
sufficiently  numerous  in  the  literature.  But  I 
do  insist  that  this  diagnosis  has  been  made  too 
often."  (Jour,  of  Nerv.  and  Ment.  Dis.,  June. 
1907.) 


CHAPTER  IX 

Multiple  Personality  and  Amnesia 

WELL  developed  cases  of  multiple 
personality  are  exceedingly  rare. 
There  are  less  than  fifty  recorded 
cases  that  possess  any  value,  and 
of  these  only  several  have  been  carefully  studied 
in  the  light  of  our  beginning  comprehension  of 
this  phenomenon.  In  view,  then,  of  the  rarity 
of  the  affection,  and  of  the  fact  that  there  is 
much  excellent  literature  devoted  to  the  sub- 
ject, it  seems  inadvisable  in  this  work  to  at- 
tempt more  than  to  summarize  several  of  the 
more  interesting  cases  and  briefly  to  describe 
the  condition. 

The  dividing  line  between  ambulatory  auto- 
matism and  multiple  personality  is  purely  arbi- 
trary; a  fugue  being  merely  a  lower  grade  of 
dissociation  that  eventuates  in  a  flight.  On  the 
other  hand,  many  of  the  cases  of  multiple  per- 
sonality exhibited  states  of  consciousness  far 
inferior,  for  instance,  to  that  of  the  secondary 
state  of  Ansel  Bourne.  One  might  well  hesi- 
tate before  deciding  whether  the  following 
case,  reported  by  Edward  E.  Mayer,  should  be 
classified  as  a  prolonged  fugue  or  as  an  instance 
of  dual  personality.  The  fact  that  two  brief 
fugues  interrupted  the  course  of  the  secondary 
state,  and  that  two  occurred  subsequently,  is 

312 


Multiple  Personality  and  Amnesia     313 

somewhat  in  favor  of  designating  the  case  as 
one  of  fugues.  When  twenty-four  years  of  age 
the  patient  had  been  in  a  railroad  wreck. 
Seventeen  years  later,  while  he  was  suffering 
acute  pain,  a  daughter  accidentally  overturned 
a  lamp.  As  he  tried  to  catch  it  he  murmured  r 
''Oh!  my  head"  and  fell  unconscious.  Upon 
recovering  consciousness,  twenty-four  hours 
later,  his  first  question  was  whether  he  was 
much  hurt.  Then  he  asked  his  wife  what 
hospital  he  was  in,  and  if  she  was  the  nurse. 
With  difficulty  he  was  convinced  that  he  was 
married,  the  father  of  four  children,  and  that 
seventeen  years  had  passed  since  the  train 
wreck.  Upon  inquiry  it  was  evident,  too,  that 
in  his  secondary  state  he  had  possessed  little 
knowledge  of  his  life  previous  to  the  accident. 
Having  reverted  to  the  primary  state  he  began 
to  worry  over  the  possibility  of  being  declared 
insane.  Sixteen  days  after  the  reversion  he  had 
a  fugue  which  carried  him  thirty  miles  away 
from  home  during  nine  hours.  The  following 
day  he  disappeared  again  and  nothing  further 
was  heard  from  him.  (Jour,  of  the  A.  M.  A., 
1901-2—1601.) 

Multiple  personality  consists  in  the  alter- 
nation of  two  or  more  distinct  personalities  the 
sum  of  whose  distinctive  characteristics  roughly 
speaking  is  equivalent  to  what  should  be  the 
normal  personality  of  the  individual.  For  in- 
stance, the  primary  personality  of  Mayer's  case 


314  Psychopathology  of  Hysteria 

cannot  be  regarded  normal  for  the  reason  that 
the  memories  of  seventeen  years  were  lacking. 
Dissociation  of  the  personality  implies  a  div- 
ision of  the  personality,  and,  consequently,  the 
faculties  of  one  state  often  are  at  the  ex- 
pense of  another.  In  other  words,  they  are 
complementary.  For  this  reason  a  hysteric  is 
never  cured,  no  matter  what  may  have  been 
her  symptoms  of  the  disease,  unless  all  of  her 
pathologically  dissociated  memories  have  been 
restored  to  consciousness. 

Multiple  personality  may  be  consequent  upon 
synthesis,  independently  of  consciousness,  of 
gradually  developing  systems  of  dissociation  of 
lesser  degree,  or  it  may  appear  suddenly  after 
some  severe  shock  or  prolonged  mental  stress. 
Often  there  occurs  a  gradually  increasing 
amount  of  dissociation  that  manifests  itself 
only  as  a  slowly  progressive  hysteria,  or  neuras- 
thenia, when  suddenly  the  patient  reverts  to  an 
older  state  of  personality  with  the  consequence 
that  she  has  had  blotted  out  the  memories  of  a 
considerable  portion  of  her  life.  It  is  during 
the  growth  of  the  secondary  personality  that 
the  patient  is  most  apt  to  consult  a  physician, 
and  she  is  treated  for  neurasthenia  or  hysteria. 
Then,  when  reversion  occurs,  the  mistake  is 
naturally  made  to  regard  as  abnormal  what 
really  approximates  more  closely  the  normal 
personality;  the  reason  for  this  being  that  in 
the  more  abnormal  state  the  patient's  memory 


Multiple  Personality  and  Amnesia     315 

included  the  events  of  her  whole  life,  but.  while 
in  the  primary  state,  memory  is  deficient  for 
the  neurasthenic  or  hysteric  period. 

In  several  of  the  early  instances  a  patient 
with  symptoms  of  hysteria,  but  in  whom  the 
existence  of  multiple  personality  was  not  sus- 
pected, was  hypnotized  for  the  purpose  of  at- 
tempting to  remove  symptoms.  Finding  that 
the  supposed  hypnotic  state  was  always  coinci- 
dent with  disappearance  of  the  symptoms,  and 
that  while  in  this  condition  the  patient  ap- 
peared to  be  normal  and  well,  what  was  be- 
lieved to  be  a  hypnotic  state  was  allowed  to 
persist  when,  in  reality,  it  was  the  normal  per- 
sonality, except  for  loss  of  memories  of  the 
secondary  state.  The  case  of  Marcelline  is  in- 
structive and  it  illustrates  the  above  misinter- 
pretation : 

Almost  in  a  dying  condition  as  a  result  of 
long  continued  hysteric  anorexia  and  vomiting 
Marcelline  was  brought  to  the  hospital.  More- 
over, she  had  urinary  retention,  her  skin  and 
mucus  membranes  were  completely  anaesthetic, 
vision  and  hearing  were  much  impaired,  and 
intellectually  she  was  deficient.  Forced  feed- 
ing being  productive  of  vomiting,  and  her  con- 
dition being  serious,  Jules  Janet  decided  to  re- 
sort to  hypnotism.  Having  hypnotized  her  and 
thus  afforded  her  an  opportunity  to  eat  without 
subsequent  vomiting  it  was  found  that  all  of 
her  symptoms  had  disappeared.    The  supposed 


316  Psychopathology  of  Hysteria 

hypnotic  state  was  dispelled  because  it  was 
thought  that  being  an  artificial  state  this  was 
necessary.  Immediately  all  of  her  former 
symptoms  returned,  and,  in  addition,  she  was 
amnesic  for  the  more  nearly  normal  state  which 
had  been  procured.  After  this  the  new  person- 
ality was  frequently  induced  in  order  to 
nourish  her.  This  state,  however,  continued  to 
be  regarded  as  hypnotic,  and  what  really  was 
a  secondary  personality  with  many  symptoms 
of  major  hysteria  was  believed  to  be  normal. 
Later,  the  "hypnotic"  personality  was  allowed 
to  persist  for  days  at  a  time  in  order  to  avoid 
the  necessity  of  going  through  the  processes  of 
hypnotizing  her  for  each  meal.  One  day  she 
was  taken  home  by  her  parents  who  had  found 
her  in  the  artificially  induced  state  and,  conse- 
quently, had  thought  that  she  had  been  cured. 

Succeeding  her  removal  from  the  hospital  the 
old  state  with  its  hysteric  symptoms  returned 
every  few  weeks,  so  that  she  was  brought  back 
to  the  hospital,  solely  to  be  hypnotized,  many 
times  during  the  following  fifteen  years  before 
her  death  from  tuberculosis.  As  each  time  she 
reverted  to  the  hysteric  personality  her  memory 
was  deficient  for  all  the  preceding  states  of  the 
primary  personality,  by  the  end  of  five  years 
she  v/as  ignorant,  when  in  the  hysteric  state, 
of  almost  all  of  her  existence  since  her  removal 
from  the  hospital.  At  the  end  of  the  fifth  year 
the  experiment  was  tried  of  allowing  her  to  re- 


Multiple   Personality  and  Amnesia     317 

main  in  the  secondary  state  several  days  in 
order  to  ascertain  if  this  deficit  was  more  ap- 
parent than  real.  Because  of  the  many  serious 
blunders  that  she  made  in  consequence  of  her 
ignorance  of  her  actions  and  life  during  these 
five  years  it  was  necessary  to  resort  again  to 
hypnotic  procedures.  (Mental  State  of  Hys- 
tericals,  p.  433.)  In  this  case,  then,  the  patient 
first  came  under  observation  during  the  exis- 
tence of  a  secondary  personality  which  was  be- 
lieved to  be  the  normal  one.  By  means  of  sug- 
gestion what  approximated  the  normal  person- 
ality was  secured  instead  of  what  should  have 
been  the  hypnotic  state,  for  which  it  was  mis- 
taken. 

Usually  certain  knowledge  is  common  to  all 
the  personalities  of  a  patient.  Thus  a  man  who 
in  the  secondary  state  is  unable  to  remember 
his  name,  or  any  of  the  incidents  of  his  past 
life,  almost  invariably  possesses  his  former 
command  of  language,  and  his  general  know- 
ledge remains  unimpaired.  Figuratively  speak- 
ing, it  is  as  if  the  line  of  cleavage  deprived  the 
new  state  only  of  that  specific  knowledge  per- 
taining to  the  former  ego;  the  new  personality 
being  the  product  of  new  experiences  and  of 
the  suppressed  tendencies  of  the  original  per- 
sonality. In  several  instances,  however,  the 
birth  of  the  secondary  personality  revealed  a 
mental  state  comparable  with  that  of  a  new 
born  infant.     In  such  cases  the  secondary  per- 


318  Psychopathology  of  Hysteria 

sonality  was  devoid  of  all  the  knowledge  that 
had  been  acquired  by  the  primary  one,  and  the 
alternating  personalities  had  nothing  in  com- 
mon. The  best  example  of  such  a  type  of  dis- 
sociation is  afforded  by  the  Hanna  case: 

While  alighting  from  his  carriage  the  Rev. 
Thomas  Carson  Hanna  made  a  misstep  and  fell, 
striking  his  head.  Upon  recovering  conscious- 
ness, two  hours  later,  his  mind  was  a  blank. 
Not  only  had  he  lost  the  faculty  of  speech,  but 
even  the  ability  to  recognize  objects  and  per- 
sons. He  was  unable  to  appreciate  distance, 
form,  size,  time,  etc.,  and  he  did  not  even  know 
how  to  use  his  muscles.  Though  the  feeling  of 
hunger  was  not  affected  yet  he  could  not  in- 
terpret the  craving,  and  he  was  ignorant  both 
of  the  purpose  of  food  and  of  the  acts  of  masti- 
cation and  deglutition.  Spatial  conceptions 
having  been  lost  he  attempted  to  grasp  a  tree 
seen  through  a  window.  Among  other  curious 
mistakes  he  thought  a  man  on  a  bicycle  con- 
stituted one  living  being,  while  a  second  man 
and  the  horse  and  carriage  that  he  was  driving 
were  another  living  being  of  a  different  kind. 
In  spite  of  his  total  amnesia  he  was  very  intelli- 
gent. At  the  end  of  one  week  of  instruction  he 
was  able  to  read,  and  six  weeks  after  the  acci- 
dent he  could  talk  intelligently.  His  dreams, 
derived  from  experiences  of  the  normal  person- 
ality, were  so  vivid  that  it  seemed  as  if  he  lived 
over  again  past  occurrences  without,  however, 


Multiple  Personality  and  Amnesia     319 

recognizing  them  as  such.  With  hypnoidi- 
zation  the  same  kind  of  hallucinations  from  the 
past  could  be  obtained.  Conservation  of  the 
memories  of  the  primary  personality  was  shown 
also  by  his  ability  to  solve  geometrical  prob- 
lems without  being  able  to  explain  how  he  did 
so. 

It  was  thought  that  a  large  number  of  stimuli 
whose  nature  differed  from  that  to  which  the 
new  personality  was  accustomed  might  raise 
above  the  threshold  of  consciousness  the  sub- 
merged memories  of  his  past  life.  If  success- 
ful, such  a  procedure  would  represent  fusion  of 
the  two  personalities.  Accordingly,  he  was 
taken  to  New  York  and  subjected  to  a  lively 
round  of  amusements.  Two  hours  after  having 
retired  he  woke  as  the  normal  Mr.  Hanna,  who 
was  much  surprised  to  find  himself  among 
strangers,  and  in  strange  quarters.  He  thought 
that  he  had  been  the  victim  of  some  practical 
joke.  During  the  following  six  days  the  two 
personalities  alternated  until  finally,  during  a 
psychic  crisis,  fusion  occurred  —  the  two  states 
became  synthetized.  (Sidis  and  Goodhart: 
Multiple  Personality,  1905.) 

With  this  patient  the  two  personalities  had 
been  entirely  ignorant  of  one  another.  Not 
any  knowledge  was  held  in  common.  Each 
alternation  was  preceded  by  a  stuporous  state 
that  was  termed  hypnoleptic.  Apropos  to  this 
state  Sidis  formulated  the  following  law:  ''no 


320  Psychopathology  of  Hysteria 

mental  alternation  ivithout  some  form  of  an  in- 
termediate sleeping  state  in  general  and  of  a 
hypnoleptic  state  in  particular,  especially  in  the 
transition  from  the  primary  to  the  secondary 
moment."  '^The  hypnoleptic  state,"  he  con- 
tinues, ^^is  the  reproduction  of  the  original  at- 
tach which  brought  about  the  state  of  double  or 
multiple  consciousness."  It  would  seem,  how- 
ever, that  such  a  twilight  state  objectively  is  not 
always  appreciable  in  all  cases,  though  no  doubt 
it  exists  subjectively.  In  the  Beauchamp  case, 
for  instance.  Prince  often  failed  at  the  time  to 
detect  an  alternation  that  took  place  in  his 
presence. 

The  Hanna  case  can  be  regarded  as  an  instance 
of  a  cure  of  dissolution  of  personality  for  the 
reason  that,  after  having  recovered,  Mr.  Hanna 
possessed  the  memories  of  both  states.  That 
the  synthesis  of  the  two  personalities  was  not 
merely  temporary  is  shown  by  Mr.  Hanna 's 
statement,  twelve  years  after  the  accident,  that 
he  had  remained  well.  (Ladies'  Home  Journal, 
Nov.,  1909.) 

Somewhat  resembling  the  Hanna  case  is  that 
of  Mary  Reynolds,  recorded  by  S.  Weir 
Mitchell.  (Trans,  of  the  Coll.  of  Physic,  of 
Phila.,  April  4,  1888.)  Mary  Reynolds  had 
been  subject  to  various  manifestations  of  hys- 
teria, when,  one  day,  she  woke  from  a  pro- 
longed sleep  in  a  state  of  complete  amnesia  for 
her  former  life.     Like  Mr.   Hanna,   when  his 


Multiple  Personality  and  Amnesia     321 

secondary  personality  had  just  appeared,  she 
was  as  a  new  born  babe,  and  did  not  even 
recognize  her  parents.  She,  too,  learned  to 
read  and  write  in  a  few  weeks.  Formerly  Miss 
Reynolds  had  been  reserved,  and  melancholic, 
but  the  alternation  of  personality  was  accom- 
panied by  an  alteration  of  disposition,  and 
she  became  cheerful,  merry  and  social.  The 
secondary  state  having  continued  five  weeks 
she  woke,  one  morning,  in  her  primary  state 
greatly  surprised  to  find  so  many  changes  had 
occurred  in  her  environment  in  the  course  of 
what  she  supposed  to  be  one  night.  She  was 
entirely  unconscious  of  the  previous  five  weeks. 
After  a  few  more  weeks  she  woke  again  in  the 
secondary  state  to  take  up  her  life  and  memo- 
ries just  where  they  had  been  interrupted  by 
the  appearance  of  the  primary  state.  The  al- 
ternations continued  to  take  place  for  fifteen 
or  sixteen  years,  but  they  finally  ceased,  leav- 
ing her  permanently  in  the  secondary  state  at 
the  age  of  thirty-five  or  thirty-six. 

As  lapses  of  memory  play  such  an  important 
part  in  the  progress  of  a  case  of  dissociated 
personality  it  might  be  thought  that  the  syn- 
drome is  merely  a  manifestation  of  systems  of 
localized  amnesias.  This,  however,  does  not 
appear  to  be  the  case,  for  while  embarrass- 
ments of  memory  are  responsible  for  many  of 
the  phenomena  of  the  condition,  alternating 
periods  of  amnesia  cannot  of  themselves  pro- 


322  Psychopathology  of  Hysteria 

duce  true  variations  in  the  personality  of  the 
patient  —  the  variations  of  tastes,  tempera- 
ment, moral  characteristics,  and  of  all  the  other 
factors  which  enter  into  the  make-up  of  what 
is  called  personality.  As  a  matter  of  fact 
amnesia  is  not  even  a  necessary  accompani- 
ment of  dissociation  of  the  personality  just  as 
succeeding  amnesia  is  not  essential  to  the  hyp- 
notic state. 

The  psychic  nature  of  manifestations  of 
hysteria  is  made  strikingly  apparent  in  many 
of  the  instances  of  multiple  personality.  For 
instance,  Louis  Vive,  whose  moral  character 
had  been  none  too  good,  and  who  had  been 
committed  for  theft,  was  bitten  by  a  viper  with 
the  consequence  that  he  had  a  convulsion  fol- 
lowed by  the  appearance  of  a  new  personality 
which  lasted  three  years.  During  the  existence 
of  this  secondary  personality  the  memory  of  his 
previous  life  was  not  greatly  impaired,  his 
moral  character  changed  decidedly  for  the 
better,  and  he  was  paraplegic,  and  subject  to 
hj^steric  convulsions.  At  the  expiration  of  the 
third  year  a  prolonged  convulsive  seizure 
ushered  in  a  new  personality,  and  immediately 
the  paraplegia  disappeared,  to  be  replaced  by 
hemiplegia  and  hemianaBsthesia.  In  this  third 
state  he  was  amnesic  for  the  whole  of  the 
second  one,  and  morally  he  had  so  deteriorated 
that  he  drank,  stole,  and  was  quarrelsome.  The 
case  was  further  complicated  by  the  develop- 


Multiple  Personality  and  Amnesia     323 

ment  of  other  personalities  with  corresponding 
variations  of  the  memory,  motals,  and  physical 
manifestations. 

Beginning  with  morbid  somnolence  and  end- 
ing with  multiple  personality  all  the  different 
kinds  of  alterations  of  consciousness  that  occur 
as  manifestations  of  hysteria  can  be  reproduced 
also  by  means  of  suggestion.  That  the  phe- 
nomena of  hyposis  are  due  to  an  artificially 
induced  dissociation  of  consciousness  has  been 
quite  generally  accepted  as  the  most  plausible 
explanation.  In  certain  individuals  it  is  possi- 
ble to  obtain  so  highly  a  developed  state  of 
what  is  called  hypnotic  somnambulism  that  to 
the  uninitiated  observer  the  state  of  the  subject 
apparently  differs  in  no  way  from  what  might 
be  regarded  normal.  While  in  this  secondary 
state  what  constitutes  the  personality  of  the 
subject  spontaneously  may  have  become 
changed,  or  quite  readily  such  alterations  may 
be  brought  about  through  the  agency  of  sug- 
gestion. In  either  case  the  condition  is  a  true 
secondary  personality  of  hypnotic  origin. 
With  certain  of  these  cases  the  new  personality 
could  be  caused  to  persist  indefinitely.  Thus, 
a  French  physician,  with  all  the  enthusiasm  of 
the  early  mesmerizers,  allowed  the  hypnotic 
personalities  of  two  sisters  to  continue  for  three 
months.  Upon  being  caused  to  revert  to  their 
usual  personalities  neither  of  these  girls  could 
remember  anything  which  had  occurred  during 
the  existence  of  the  secondary  states. 


324  Psychopathology  of  Hysteria 

A  well  developed  case  of  multiple  personality 
originating  from  the  abuse  of  hypnotism  is  that 
of  Pierre  Janet's  patient  Madame  B.  This  pa- 
tient had  possessed  a  good  foundation  for  the 
development  of  multiple  personality  in  that  she 
had  been  subject  to  attacks  of  nocturnal  som- 
nambulism since  her  third  year.  After  having 
attained  the  age  of  sixteen  years  she  had  con- 
stantly been  used  by  laymen  and  physicians  as 
a  subject  for  hypnosis.  The  hypnotic  state  had 
been  induced  so  frequently,  and  while  in  this 
state  she  had  been  subjected  to  so  much  experi- 
mentation and  clinical  education,  that  a  well 
organized  hypnotic  personality — Leontine — 
had  become  elaborated;  one  which  differed 
completely  from  Leonie,  the  ''normal" 
Madame  B.  Leonie,  a  poor  peasant,  was  a  seri- 
ous, timid,  melancholy  woman,  while  Leontine 
was  gay,  noisy,  restless,  and  ironical.  The 
memory  of  Leonie  was  impaired — she  was 
amnesic  for  all  the  periods  when  Madame  B.  's 
other  personalities  were  uppermost.  Though 
Leontine 's  memory  included  that  of  Leonie,  she 
separated  the  two  states  and  looked  upon  as 
her  own  only  the  memories  of  events  which  oc- 
curred when  her  own  personality  controlled  the 
body  of  Madame  B.  Thus  Leontine  considered 
her  husband  as  belonging  to  ''that  good  wo- 
man" "the  other"  who  "is  not  I,  she  is  too 
stupid";  but  the  children  she  called  her  own 
because  they  were  born  while  Madame  B.  was 


Multiple  Personality  and  Amnesia     325 

in  a  hypnotic  state ;  induced  for  the  purpose  of 
rendering  the  event  painless.  "Wlien  Leontine 
was  subjected  to  further  hypnotic  procedures 
there  appeared  a  third  personality,  known  as 
Leonore,  who  did  not  wish  to  be  mistaken  for 
that  "good,  but  stupid,  woman"  Leonie  nor 
for  the  ''foolish  babbler"  Leontine.  The 
Leonore  personality  seemed  superior  to  either 
of  the  others  both  in  respect  to  character  and  to 
memory,  which  included  the  whole  of  Madame 
B.'s  life.  (Revue  Philosophique,  Mar.  1888. 
The  above  account  is  based  upon  the  abstracts 
of  Prof.  James  and  of  F.  W.  H.  Myers.) 

The  most  interesting  of  the  cases  of  psychic 
polyzoism  is  the  complex  Beauchamp  case  which 
was  studied  so  exhaustively  by  Morton  Prince. 
It  is  the  careful  analysis  of  this,  and  of  other 
similar  cases,  that  has  been  productive  of  much 
valuable  information  concerning  functional  am- 
nesia, pathogenic  submerged  memory  com- 
plexes, association  of  ideas,  the  subconscious,  and 
many  other  of  the  problems  of  morbid  psychol- 
ogy.    (The  Dissociation  of  a  Personality,  1906.) 

In  her  early  life  Miss  Beauchamp  had  been  de- 
cidedly neurotic.  One  day,  in  1893,  she  was  sub- 
jected to  a  number  of  stresses  culminating  in  an 
unpleasant  experience  whose  importance  was  great- 
ly exaggerated  by  her,  and  which  resulted  in  the 
birth  of  a  new  personality — B.  I.  Like  Leontine, 
and  the  secondary  personalities  of  Louis  Vive, 
and  of  Marcelline,  B.  I  did  not  present  any  gross 


326  Psychopathology  of  Hysteria 

impairment  of  the  memories  of  her  previous 
life.  Being  the  subject  of  a  decided  neuras- 
thenic-like state  she  came  under  the  care  of 
Dr.  Prince  in  1898.  Resorting  to  hypnosis, 
Prince  secured  a  somnambulistic  state  which 
was  superior  to  the  B.  I  personality  and  which 
he  utilized  as  a  means  of  obtaining  the  bene- 
ficial effects  of  suggestion.  Soon,  however,  a 
new  personality — Sally — sprung  out  of  the  hyp- 
notic state  without  having  been  produced  arti- 
ficially by  suggestion.  This  new  personality 
apparently  had  been  a  co-conscious  one  the 
whole  of  Miss  B.'s  life,  and  it  continued  to 
be  co-conscious  even  during  sleep,  delirium, 
etherization,  and  whenever  the  B.  I  state  was 
in  the  ascendancy.  But,  following  its  emancipa- 
tion during  hypnosis,  it  became,  also,  a  true 
alternating  personality.  Sally  was  superior  to 
B.  I  in  that  she  was  not  amnesic,  and  she  was 
co-conscious  with  the  latter.  B.  I  however, 
was  ignorant  of  all  that  concerned  Sally. 

A  year  after  Sally  appeared  upon  the  scene,  B. 
I  had  been  caused,  by  chance  association  of  ideas, 
to  recall  the  primary  pathogenic  experience 
with  the  consequence  that  still  another  person- 
ality developed.  This  one,  B.  IV  remembered 
her  former  life  up  until  the  dissolution  of 
personalitj^ — she  knew  nothing  of  B.  I,  nor  of 
Sally,  and  they,  in  turn,  were  ignorant  of  her 
memories. 

Let  us  examine,  now,  the  differences  in  the 


Multiple  Personality  and  Amnesia     327 

personalities.  In  addition  to  being  subject  to 
spontaneous  somnambulism,  B,  I  was  extremely 
neurasthenic,  aboulic,  morbidly  reticent,  sensi- 
tive and  emotional.  Among  other  good  quali- 
ties, she  was  modest,  conscientious,  truthful, 
refined,  well  educated,  and  a  bibliophile.  Hav- 
ing studied  stenography  and  the  French  lan- 
guage after  the  disintegration  of  personality 
had  occurred  this  knowledge,  in  common  with 
other  knowledge  pertaining  to  the  B.  I  state, 
was  not  shared  with  Sally  and  B.  lY. 

Like  those  of  B.  IV,  the  qualities  of  the  Sally 
personality  were  complementary  to  B.  I.  De- 
spising B.  I  on  account  of  her  popularity,  su- 
perior attainments,  and  poor  health,  Sally 
was  mischievous,  childish,  impolite,  rebellious 
and  fond  of  slang.  In  addition  to  her  occur- 
rence as  an  independent  personality,  and  as  a 
co-conscious  state  with  B.  I,  Sally  was  partially 
co-conscious  with  B.  IV  in  that  she  was  aware 
of  the  actions  and  the  words,  but  not  of  the 
thoughts  of  B.  lY.  By  means  of  obsessions  she 
could  control  the  actions,  and  even  the  percep- 
tions, of  B.  I  and  B.  IV.  Subjectively,  her 
health  was  excellent,  though  she  was  totally 
anaesthetic  and  without  the  senses  of  hunger, 
thirst,  fatigue,  and  of  time. 

The  personality  of  B.  IV  was  superior  either 
to  Sally  or  to  B.  I.  Though  neurasthenic,  her 
health  was  fair.  She  was  ambitious,  selfish, 
affable,  and  had  no  compunction  about  lying 


328  Psychopathology  of  Hysteria 

whenever  necessary.  The  only  knowledge  she 
had  of  B.  I  was  obtained :  1,  from  isolated  mem- 
ory flashes;  2,  by  means  of  crystal  vision;  3, 
through  the  agency  of  self-induced  states  of 
abstraction  she  could  evoke  visual  and  auditory 
hallucinations  concerning  B.  I.  She  could  not 
revive  any  of  the  memories  of  the  Sally  state. 

Until  the  normal  personality  was  obtained^ 
in  1902,  by  suggesting  to  the  hypnotic  personal- 
ity that  it  should  ' '  wake ' '  from  hypnosis  with- 
out becoming  disassociated  either  into  B.  I  or 
into  B.  IV,  all  of  the  personalities  continually 
alternated.  Often  the  alternations  occurred 
many  times  in  the  course  of  a  day.  At  other 
times  one  personality  might  remain  in  the 
ascendancy  for  weeks  at  a  time.  After  the 
normal  Miss  B.  had  been  obtained  all  of  the 
personalities  alternated  infrequently  until,  in 
1905,  the  synthesis  became  permanent.  It  is 
interesting  to  note  that  early  in  the  case  Prince 
believed  that  if  the  hypnotic  personality  could 
be  wakened  without  losing  its  identity  the 
normal  Miss  B.  would  be  secured.  On  attempt- 
ing to  do  so,  however,  he  had  produced  what 
resembled  a  state  of  dementia.  The  explana- 
tion afterwards  came  from  the  mischievous 
Sally,  who,  not  wishing  to  sacrifice  her 
independence,  had  been  able,  as  a  co-conscious 
personality,  to  bring  about  this  dementia-like 
state. 

The  normal  Miss  B.  represented  union  of  the 


Multiple  Personality  and  Amnesia     329 

B.  I  and  B.  IV  personalities;  Sally,  the  co- 
conscious  personality,  being  necessarily  included 
in  the  synthesis.  In  this  case  the  production  of 
a  normal  personality  by  means  of  hypnosis  il- 
lustrates how  the  supposed  abnormal  hypnotic 
states  were  really  the  normal  personalities  of 
Marcelline  and  of  other  reported  cases. 

The  following  notes  include  some  of  the 
unique  and  interesting  features  of  the  Beau- 
champ  case  :  The  personalities  Sally  and  B.  IV 
did  their  best  to  prevent  synthesis  because  each 
desired  to  maintain  an  independent  existence. 
In  fact,  Sally  disrespectfully  upbraided  Dr. 
Prince  on  one  occasion  solely  because  the  suc- 
cess of  his  efforts  to  cure  Miss  B.  would  neces- 
sitate the  conclusion  of  her  o^vn  independent 
existence.  In  their  attempts  exclusively  to 
reign  over  the  body  of  Miss  B.  both  Sally  and 
B.  IV  carried  on  a  bitter  and  spirited  warfare 
in  which,  at  times,  they  seemed  to  forget 
that  when  the  body  of  Miss  B.  became  the 
instrument  of  their  hostilities  each  of  the 
personalities  also  would  suffer.  To  illustrate 
the  extremes  to  which  the  struggle  was  carried, 
once  Sally  took  four  calomel  pills  and  then 
resigned  the  body  of  Miss  B.  to  B.  IV.  Another 
time  she  smoked  a  number  of  cigarettes  in 
order  to  make  B.  IV  ill.  On  still  another  occa- 
sion she  had  partaken  of  wine,  and  then,  prob- 
ably by  accident,  instead  of  changing  to  B.  IV, 
the  inoffensive  B.  I,  who  was  unaccustomed  to 


330  PsychopatJiology  of  Hysteria 

wine,  arrived  on  the  scene  to  find  herself  some- 
what intoxicated.  Indeed,  B.  I  became  so 
harassed  by  the  protracted  contest  that  once 
she  tried  to  commit  suicide  with  illuminating 
gas,  but  Sally  came  to  the  rescue  by  turning 
off  the  gas  and  opening  the  windows. 

The  differences  in  the  character  of  the  per- 
sonalities was  most  decided.  Thus  B.  I  could 
not  take  a  single  glass  of  wine  without  feel- 
ing uncomfortable,  while  B.  IV  had  taken, 
without  any  such  effects,  as  many  as  three  or 
four  glasses  of  champagne,  followed  by  three 
or  four  cocktails  and  several  glasses  of  liqueur. 
The  odor  of  cigarettes  was  offensive  to  B.  I  and 
she  had  moral  objections  to  smoking,  but  B. 
IV  was  very  fond  of  cigarettes,  of  which  she 
smoked  a  large  number  without  feeling  any  ill 
effects.  In  fact,  the  tastes  and  the  religious 
and  other  moral  characteristics  of  B.  IV  were 
almost  the  opposite  of  those  of  B.  I. 

In  instances  like  the  Hanna  ease,  in  which 
the  personality  presumably  had  been  entirely 
normal  until  some  violent  shock  effected  imme- 
diate dissociation  with  the  production  of  a 
secondary  state  that  was  infantile  in  type,  it 
seems  that  but  two  states  exist  for  the  reason 
that  the  secondary  one  is  largely  the  product 
of  new  experiences  and  thus  is  not  formed  at 
the  expense  of  the  normal  one.  When  a  nor- 
mal person  develops  obvious  manifestations  of 


Multiple   Personality  and  Amnesia     331 

hysteria  dissociation  of  his  personality  already 
has  occurred  and,  in  reality,  there  exist  two 
secondary  personalities ;  one  being  apparent 
and  the  other  latent.  The  only  reason  why  the 
latent  one  does  not  commonly  appear  as  an 
alternating  personality  is  because  it  is  too 
fragmentary  to  maintain  an  independent  exist- 
ence. Clinically  it  is  possible  in  the  ordinary 
case  of  hysteria  to  demonstrate  the  existence  of 
such  incomplete  personalities.  In  the  cases  of 
multiple  personality  of  gradual  onset  we  can 
assume,  therefore,  that  there  are  always  at  least 
three  personalities :  the  normal  one,  the  grad- 
ually developed  hysteric  personality,  and  its 
complement.  The  prevention  of  alternation  of 
the  personalities  of  such  cases  does  not  consti- 
tute a  cure :  the  secondary  personalities  must  be 
fused  before  the  normal  one  can  be  obtained. 
In  the  Beauchamp  case,  for  instance,  if  either 
the  B.  I  or  B.  rV  personalities  could  have  been 
prolonged  indefinitely  without  alternation  the 
result  would  not  have  been  a  cure  for  the 
reason  that  neither  of  these  personalities 
represented  the  normal  Miss  B. 

All  of  us  have  probably  experienced  tenden- 
cies to  do  things  which  were  inconsistent  with 
conduct  conformable  with  the  obligations  im- 
posed by  occupation,  finances,  home  life,  social 
status,  etc.  Being  incompatible  with  our  ex- 
ternal relations,  such  thoughts  were  sup- 
pressed.    Simply  being  submerged,  these  ideas 


332  Psychopathology  of  Hysteria 

continue  to  exert  a  modifying  influence  upon 
the    better    side    of    the    ego,    thus    producing 
what  might  be  called  an  average  personality. 
In  fact,  we  are  all  both  better  and  worse  than 
we  appear  to  be  to  others,  and  our  personalities, 
both  as  viewed  by  others  and  by  ourselves,  are 
merely  masks  which  serve  to  screen  the  pos- 
sibilities for  good  or  evil  that  exist  within  us. 
Under  favorable   circumstances   one   who  has 
been   a   criminal  may  live   as   an   average   in- 
dividual,  while  if  we  should  transfer  the  ex- 
ceptional person  to  an   environment  where  he 
is  exposed  to  various  stresses,  we  might  bring 
into  evidence  traits  which  neither  he  nor  his 
friends     ever    suspected.     When    dissociation 
occurs  it  is  but  natural  that  one  personality 
should  be  lively  and  not  too  scrupulous  while 
the  other  exhibits  puritanical  tendencies.  Study 
of    most    of    the    reported    cases    of    multiple 
personality    shows    this    difference    of    moral 
characteristics. 

Amnesia.  Organic  failure  of  memory  is 
characterized  by  loss  of  the  recently  acquired 
memories,  followed  by  progressive  obliteration 
of  the  older  and  more  stable  ones.  Ordinarily 
the  mechanism  of  amnesia  is  divided  into 
defects  of  registration,  of  conservation,  and  of 
reproduction.  To  speak  of  an  amnesia  resulting 
from  imperfect  registration,  however,  is  not 
logical,  for  what  has  not  been  registered  cannot 


Multiple  Personality  and  Amiiesia     333 

be  forgotten — one  cannot  lose  something  which 
he  never  possessed. 

It  is  well  known  that  functional  amnesia  is 
never  due  to  absence  of  conservation — to 
actual  loss  of  memorv — but  that  it  is  merely 
consequent  upon  the  patient's  inability  con- 
sciously to  reproduce  the  "forgotten"  mem- 
ories. Through  the  agency  of  certain  well- 
tnown  means  proof  of  this  fundamental  propo- 
sition is  obtainable  without  difficulty,  and  it  is 
possible  to  demonstrate  that  what  has  been 
forgotten  has  only  been  dissociated  from  con- 
sciousness, and,  therefore,  has  not  been  lost. 
Instead,  then,  of  being  a  loss  of  memory  the 
amnesia  of  hysteria  is  merely  the  result  of 
elision  from  consciousness  of  certain  systems 
of  memories  which  subconsciously  are  con- 
served, or  are  part  of  a  parasitic  personality 
made  up  by  synthesis  of  other  dissociated 
memories  and  mental  states.  But,  all  kinds  of 
functional  amnesia  are  not  explainable  in  this 
manner.  The  memories  of  events  which 
occurred  during  any  of  the  many  kinds  of 
seizures  or  somnambulistic  conditions — devi- 
ations from  the  usual  state  of  consciousness 
— are  bound  up  with  the  memory  complexes  of 
that  state,  so  that  ordinarily  they  are  incapable 
of  conscious  reproduction  because  they  had 
never  been  components  of  the  usual  state  of 
consciousness  of  the  patient.  During  recur- 
rences of  like  somnambulistic  conditions  these 


334  Psychopathology  of  Hysteria 

dissociated  memories  become  part  of  the  state 
of  the  patient's  consciousness  at  the  time  be- 
cause they  pertain  to  that  state  and  not  to  the 
usual  one.  It  is  the  same  with  what  is  called 
hypnotic  somnambulism.  During  this  artificial 
state  the  patient  is  capable  of  remembering  the 
events  of  all  previous  states  of  like  nature,  yet, 
when  aroused  from  hypnosis,  all  of  these  mem- 
ories become  dissociated. 

Quite  commonly  hysterics  complain  of  their 
poor  memories  and  state  that  they  cannot  even 
remember  what  thej*  have  been  told  a  minute 
before  or  what  they  have  had  for  breakfast. 
Tell  a  hysteric  to  do  something  and  usually  she 
will  not  carry  out  the  instructions  correctly 
unless  they  are  repeated.  Ask  her  what  you 
have  told  her,  and  she  will  answer  that  she 
doesn't  know,  or  that  she  has  forgotten.  All 
of  this,  however,  is  not  evidence  of  amnesia. 
The  patient  did  not  pay  any  attention  to  what 
she  was  eating,  and  you  could  plainly  see  that 
she  was  thinking  about  something  else  while 
you  were  talking  to  her.  A  man  whose  atten- 
tion has  been  concentrated  upon  his  work,  and 
who  has  been  thinking  deeply,  not  only  is 
unable  to  tell  what  hour  was  struck  the  minute 
before,  but  he  may  be  consciously  unaware  even 
that  the  hour  has  been  sounded.  Neither  can 
we  call  this  ordinary  incident  amnesia,  for  there 
was    absence   of   conscious   perception   of   the 


Multiple  Personality  and  Amnesia     335 

striking  of  the  clock,  and  of  the  same  nature 
is  much  of  the  so-called  amnesia  of  hysteria. 

The  pseudo-amnesia  of  inattention  might 
serve  as  the  foundation  from  which  by  auto- 
suggestion, or  expectant  attention,  different 
kinds  of  functional  amnesia  might  be  evolved. 
The  symptomatic  loss  of  memory  occasioned  by 
trauma,  and  by  an  alcoholic  debauch,  or  other 
toxic  state,  also  might  attract  the  patient's 
attention  to  the  possibility  of  this  symptom. 
Finally,  amnesia  is  autogenous  when  it  occurs 
as  one  of  the  phenomena  of  some  alteration  of 
consciousness. 

When  physicians  specifically  interrogate 
hysteric  patients  about  general  deterioration  of 
memory,  or  about  definitely  localized  loss  of 
memory,  they  reveal  by  their  direct  questions 
that  these  manifestations  are  to  be  expected. 
Consequently,  sooner  or  later  the  patients  very 
accommodatingly  begin  to  exhibit  amnesias 
originating  from  unconscious  autosuggestion, 
and  which  cannot  be  regarded  as  differing  in 
any  manner  from  those  which  are  deliberately 
produced  by  suggestion,  either  during,  or  in 
the  absence  of,  hypnosis.  Except  the  localized 
amnesias  incidental  to  the  attacks  of  hysteria — 
convulsive,  somnambulistic,  etc. — one  rarely 
encounters  independent  amnesia  in  hysterics 
unless  they  have  been  subjected  to  suggestive 
inquiries  which  tend  to  bring  about  the  co^^di- 
tion  which  is  sought. 


336  Psychopathology  of  Hysteria 

An  interesting  feature  which  renders  psy- 
choanalysis and  treatment  more  difficult  is  that 
the  amnesias  of  attacks  are  inclined  to  be  re- 
trograde inasmuch  as  the  primary  and  individ- 
ual causes  are  forgotten.  So  also  the  patient 
usually  is  not  consciously  aware  of  the  initial 
exciting  cause  of  her  disease.  Thus,  Janet's 
patient  Marie,  whose  case  has  already  been 
mentioned,  had  completely  forgotten  about  the 
successful  and  disastrous  suppression  of  her 
first  menstrual  period,  and  Sallie  S.  did  not 
remember  that  her  attacks  followed  references 
to  her  dead  child.  The  explanation  depends 
upon  reaction  of  defense. 

As  the  exciting  cause  of  hysteria  and  of  its 
manifestations  frequently  is  some  experience 
which,  being  decidedly  unpleasant  to  the 
patient,  she  endeavored  to  forget,  its  memory 
complex  became  elided  from  consciousness  with 
that  facility  with  which  dissociation  occurs  in 
hysteria.  Furthermore,  any  idea  which  by 
association  causes,  or  tends  to  cause,  reproduc- 
tion of  the  painful  memories,  itself  is  disposed 
to  become  a  component  of  the  submerged 
complex,  which  continually  increases  in  mag- 
nitude with  corresponding  increase  in  liabil- 
ity to  automatisms.  ''We  ask,"  writes  Ernest 
Jones,  (Jour,  of  Abnormal  Psych.,  vol.  4,  p. 
224,)  "why  the  patient  wished  to  forget  the 
memories  in  question,  and  we  find  it  was  be- 
cause they  are  associated  with  other  more  pain- 


Multiple  Personality  and  Amnesia     337 

ful  thoughts  he  did  not  wish  to  recall.  We 
then  go  on  to  ask  why  these  other  thoughts 
were  too  painful  to  recall,  and  we  get  a 
precisely  similar  answer,  namely  because  they 
are  associated  with  yet  deeper  thoughts  which* 
he  was  still  more  desirous  not  to  recall.  We 
continue  the  investigation  in  the  same  way, 
constantly  asking  'Wliy?'  and  constantly  pen- 
etrating deeper  and  deeper  into  the  patient's 
mind,  and  reading  further  and  further  back 
into  his  earliest  memories.  The  pathogenic 
chain  of  associations  is  in  this  way  traced  to 
its  original  starting  point." 

An  instructive  case  of  psychasthenia  exhib- 
ited in  an  unmistakable  manner  the  incom- 
patibility of  dissociated  memories  with  con- 
sciousness. Though  possessing  a  nervous  tem- 
perament the  patient  had  never  really  been  ill 
or  subject  to  unequivocal  nervous  manifesta- 
tions until  she  was  confined  to  bed  four  months 
as  the  result  of  an  attack  of  "nervous  prostra- 
tion" which  occurred  four  years  before  coming 
under  my  observation.  Following  the  illness 
she  became  obsessed  with  indefinite  fear  which 
compelled  her,  no  matter  how  much  she  re- 
sisted, continually  to  look  behind  her.  This 
phobia  attacked  her  impartially  at  any  time, 
and  in  any  place.  When  interrogated  she 
stated  that  she  believed  the  apprehension  to  be 
based  upon  unreasoning  fear  of  being  struck 
from  the  rear,  but  she  was  positive  in  her  as- 


338  PsycJiopathology  of  Hysteria 

sertions  of  ignorance  of  its  cause.  Frequently 
she  experienced  visual  hallucinations  of  a  sea 
of  blood. 

Attempts  to  induce  hypnosis  resulted  only 
in  a  hypnoidal  state,  during  which  the  patient 
insisted  that  she  was  not  at  all  influenced, 
even  though  unable  to  open  her  eyes.  During 
her  second  visit  a  hypnoidal  state  again  was 
induced,  and  efforts  were  made  to  discover  the 
causes  of  her  different  manifestations.  On  this 
occasion  it  required  five  minutes  of  persuasion 
and  suggestion  before  she  could  be  prevailed 
upon  to  talk.  Afterwards  she  confessed  that 
her  reluctance  was  due  to  a  desire  to  show  me 
that  she  was  not  hypnotized,  and  that  she  did 
not  have  to  do  as  I  said.  With  the  patient  in 
this  imperfect  hypnotic  state  the  following  in- 
formation was  obtained  : 

The  attack  of  *' nervous  prostration"  was 
precipitated  by  a  quarrel  during  which  her 
mother  threatened  to  kill  her.  (The  patient 
herself  was  a  mild-mannered  and  most  inoffen- 
sive woman.)  She  believed  her  mother  was  in- 
sane but  was  reluctant  to  express. this  opinion 
because  it  was  contrary  to  that  of  a  physician. 
Following  her  illness  the  visual  hallucination 
of  blood  appeared,  at  first  only  after  disputes 
with  her  mother,  but  the  tendency  for  their 
recurrence  became  so  developed  and  so  ex- 
panded that  soon  they  occurred  after  minor 
quarrels  with  anyone.     The  irresistible  impul- 


Multiple  Personality  and  Amnesia     339 

sion  to  look  behind  her  appeared  about  four 
months  after  the  quarrel,  and  was  due,  she  said, 
to  fear  of  being  struck  on  the  head.  This 
obsession  originally  disturbed  her  only  when 
she  was  at  home,  and  it  was  a  manifestation 
of  fear  that  her  mother  would  carry  out  her 
threat.  Later,  the  tendency  of  the  psycho- 
neuroses  pathologically  to  exaggerate  what  pri- 
marily were  normal  reactions  caused  this  justi- 
fiable fear  to  become  so  expanded  and  so  incon- 
gruous that  it  occurred  anywhere,  and  with- 
out unusual  provocation.  Being  of  a  painful 
nature  the  memory  complex  of  the  cause  of  the 
original  normal  reaction  was  suppressed  from 
consciousness  so  that  ultimately  the  patient 
became  unaw^are  of  the  origin  of  the  phobia 
and  of  other  manifestations  which  resulted 
from  the  quarrel. 

After  her  usual  state  of  consciousness  was 
restored  she  asserted,  as  before,  that  she  had 
not  been  hypnotized,  and  that  she  did  not  wish 
to  deceive  me  by  allowing  me  to  think  other- 
wise. Although  she  could  recall  much  of  what 
had  been  said  during  the  hypnoidal  state,  and 
notwithstanding  that  she  believed  that  she  re- 
membered the  entire  conversation,  it  became 
apparent,  however,  that  she  was  unaware  of 
the  ivhole  of  what  she  had  said  in  connection 
with  the  genesis  of  all  of  her  many  symptoms. 
Incidentally,  her  suicidal  tendencies,  phobias, 
and   other   obsessions   disappeared   completely 


340  Psychopathology  of  Hysteria 

after  their  origin  was  explained  to  her,  and 
after  she  had  received  four  treatments  with 
suggestion  and  psychic  re-education. 

Anterograde,  or  continuous,  amnesia  is  the 
result  of  dissociation  of  memories  almost  as 
soon  as  they  are  formed  and  to  a  great  degree 
probably  depends  upon  inattention.  The  most 
celebrated  example  of  this  defect,  in  association 
with  retrograde  amnesia,  is  the  case  of  Madame 
D.,  which  was  studied  by  Charcot,  Souques  and 
Janet.  Having  been  told  falsely  that  her  hus- 
band was  being  brought  home  dead  Madame  D. 
had  an  attack  of  hysteric  convulsions  and 
delirium  that  continued  for  three  days.  Fol- 
lowing the  crisis  not  only  was  she  unable  to 
remember  all  that  had  occurred  during  the  two 
preceding  months,  but  for  nine  months  she 
continued  to  forget  whatever  occurred  the 
minute  before. 

Amnesias  are  localized  when  whole  periods 
are  blotted  out,  and  they  occur  in  this  manner 
in  almost  all  patients  who  are  subject  to  the 
attacks  of  hysteria.  This  form  of  defective  re- 
production is  most  obtrusive  in  connection 
with  the  alternations  of  fugues  and  of  multiple 
personality  because  the  forgotten  periods  are 
longer  than  those  of  other  states  of  disturb- 
ance of  consciousness,  and  because  these  alter- 
nations do  not  incapacitate  the  patient  from 
maintaining  his  external  relations.  Naturally 
it  is  important  that  one  should  remember  what 


Multiple   Personality  and  Amnesia     341 

new  acquaintances  have  been  formed,  what  en- 
gagements have  been  made,  or  where  money 
has  been  safely  placed  away  during  the  preced- 
ing days,  or  weeks,  or  months. 

When  the  patient  is  unable  to  remember 
certain  systems  of  knowledge  the  amnesia  is 
systematized.  Not  only  is  the  following  case, 
reported  by  Breuer  and  Freud,  a  beautiful  ex- 
ample of  systematized  amnestic  aphasia,  but  it 
illustrates  well  the  manner  in  which  the  de- 
velopment of  symptoms  may  be  deferred.  One 
night,  while  somewhat  confused  and  exhausted 
from  nursing  her  father,  Praiilein  Anna  0. 
experienced  a  hallucination  which  frightened 
her.  At  first  she  was  unable  to  recall  any 
words;  then  she  remembered  an  English 
prayer.  Subsequently,  on  developing  grave 
hysteria  whose  symptoms  were  based  mainly 
on  the  incidents  of  her  father's  fatal  illness, 
she  lost  entirely,  for  a  period  of  a  year  and  a 
half,  the  use  and  comprehension  of  the  German 
language  while  retaining  her  command  of 
English.  (Selected  Papers  on  Hysteria  and 
Other  Psychoneuroses,  trans,  by  A.  A.  Brill, 
1909,  p.  2.) 

As  already  mentioned,  the  proof  that  the 
amnesias  of  hysteria  are  not  dependent  upon 
irretrievable  loss  of  memories — faulty  conser- 
vation— rests  with  the  successful  application 
of  measures  having  as  their  end  the  reproduc- 
tion of  what  has  been  forgotten.     First,  how- 


342  Psychopathology  of  Hysteria 

ever,  let  us  consider  several  of  the  ways  in 
which  spontaneously  the  patient  gives  evidence 
that  the  lost  memories  are  really  retained,  and 
that  the  loss  consists  only  in  the  patient's  in- 
ability consciously  to  recall  them.  Investiga- 
tion of  the  dreams  of  hysterics  ordinarily  shows 
that  they  are  composed  of  the  very  memories 
which  have  been  dissociated.  For  instance, 
in  the  Ilanna  case  of  dual  personality  vivid 
dreams  occurred  which,  upon  investigation, 
were  found  to  contain  elements  of  what  had 
happened  prior  to  dissociation.  Such  dreams 
included  the  names  of  persons,  of  objects,  and 
of  places  which  in  his  secondary  state  were 
meaningless  to  him. 

In  the  course  of  the  various  attacks  of  hys- 
teria quite  as  common  is  the  display  of  knowl- 
edge of  incidents  which  could  not  be  recalled 
during  the  usual  state  of  consciousness.  Not 
only  by  their  actions  but  also  by  their  verbal 
utterances  do  these  patients  show  recollection 
of  what  consciously  cannot  be  remembered. 
Moreover,  both  the  hallucinations  which  are 
experienced  during  less  obvious  alterations  of 
consciousness,  and  the  memory  flashes  which 
occur  so  frequently  in  cases  of  multiple  per- 
sonality, indubitably  establish  the  preservation 
of  memories  which  may  have  been  deemed  ir- 
recoverable. 

As  the  loss  of  memory  is  always  more  ap- 
parent than  real,  and  as  the  trouble  depends 


Multiple  Personality  and  Amnesia     343 

solely  upon  defective  reproduction,  the  physi- 
cian must  assume  that  the  patient  knows  the 
facts  which  are  desired,  and  to  be  successful 
he  must  not  permit  the  patient  to  gain  the  idea 
that  any  doubt  is  entertained  relative  to  the 
outcome  of  the  investigation,  and  professions 
of  ignorance  never  should  be  accepted.  Since 
recurrence  of  seizures  is  effected  by  association 
of  ideas  which  produce  an  upward  flow  into 
consciousness  of  dissociated  systems  with  their 
morbid  psychomotor  expression,  efforts  to  re- 
produce pathogenic  complexes  may  be  attended 
with  the  production  of  the  attacks  with  which 
they  are  associated.  This,  however,  is  unusual 
and  is  easily  prevented  by  suggestion,  or  the 
attack  cut  short  by  the  same  means.  Much 
valuable  information  can  be  acquired  through 
the  induction  of  a  single  crisis,  but  it  is  de- 
cidedly unwise  to  encourage  the  pathologic 
disposition  by  unnecessary  reproduction  of 
seizures. 

Inasmuch  as  functional  lapses  of  memory 
are  due  to  the  objectionable  nature  of  what 
lias  been  forgotten,  in  his  efforts  to  bring  about 
reproduction  the  physician  has  to  contend  with 
the  forces  of  the  patient  which  strive  to  pre- 
vent the  submerged  memories  from  becoming 
conscious.  The  more  nearly  the  patient's  state 
of  consciousness  approaches  that  which  is 
usual  the  greater  the  amount  of  unconscious 
inhibition  exerted  towards  the  prevention  of 


344  Psychopathology  of  Hysteria 

reproduction.  When  through  the  agency  of 
hypnotic  procedures  we  effect  an  artificial 
dissociation  of  consciousness  inhibition  of  the 
submerged  memories  to  a  great  extent  is  lost, 
and,  therefore,  the  patient  is  able  to  relate  the 
experiences  which  she  cannot  remember  while 
in  her  normal  state.  In  the  psychoanalysis  of 
those  whom  we  may  term  good  hypnotic  subjects 
the  hypnotic  method  is  by  far  the  least  difficult 
in  its  application  and  the  most  prolific  of  the 
information  which  is  sought. 

Not  every  hysteric  can  be  hypnotized  so  deeply 
as  to  become  somnambulic.  The  best  means  of 
obtaining  profound  hypnosis  consists  in  explain- 
ing beforehand  what  is  about  to  be  done  and 
what  condition  is  about  to  be  secured.  Pro- 
ceeding, then,  to  hypnosigenesis,  the  physician 
attempts  by  means  of  further  suggestions  to 
induce  somnambulism.  But,  if  the  desired 
state  is  not  obtained — as  will  occur  in  from 
10-30%  of  cases — the  physician  who  has  pre- 
dicted, and  who  is  suggesting  the  appearance 
of,  conditions  that  do  not  materialize,  thereby 
not  only  subjects  himself  to  embarrassment,  but 
he  loses,  to  a  certain  extent,  the  patient's  con- 
fidence. Consequently,  under  these  circumstan- 
ces reproduction  of  the  submerged  memories  is 
usually  difficult,  if  not  impossible. 

In  order  to  avoid  these  difficulties  Freud 
(Selected  Papers  on  Hysteria,  Brill  trans.) 
adopted  the  following  technique :    Having  the 


Multiple   Personality  and  Amnesia     345 

patient  lie  down  with  the  eyes  closed,  he  re- 
quires her  to  concentrate  her  attention  on  what 
is  about  to  be  done.  In  this  manner  he  obtains 
as  profound  a  state  of  hypnosis  as  possible 
without,  however,  compromising  himself  by 
making  false  predictions  and  unsuccessful  sug- 
gestions. While  the  patient  relates  her  history 
gaps  become  apparent;  she  avoids  certain 
periods,  or  leaves  out  causal  events.  When 
urged  to  remember  the  important  memory 
complexes  which  these  gaps  represent  she  often 
protests  that  she  cannot.  Accordingly,  an 
artifice  is  adopted  which  depends  upon  rein- 
forced suggestion.  Placing  his  hand  upon  the 
patient's  forehead,  Freud  affirms  that  under 
the  pressure  of  his  hand  the  desired  informa- 
tion will  come  into  her  mind,  or  that  she  will 
see  some  picture  before  her.  Soon  he  found 
that  all  thoughts  secured  in  this  manner  were 
relevant,  and  that  a  negative  response  never 
should  be  accepted,  for  when  the  procedure  at 
first  is  unsuccessful  the  failure  does  not  indi- 
cate that  the  right  thought  did  not  come  into 
the  patient's  mind,  but  that,  being  of  a 
distressing  nature,  it  was  repudiated  as  irrele- 
vant, or  too  painful  to  entertain,  just  as 
originally  the  complex  was  submerged. 

By  means  of  the  hypnoidal  state  Sidis, 
Coriat,  White,  Donley,  Parker,  and  others  have 
been  very  successful  in  the  psychoanalysis  of 
functional  neuroses.     The  hypnoidal  state  of 


346  Psychopathology  of  Hysteria 

Sidis  consists  in  an  unstable  state  of  abstrac- 
tion that  intervenes  between  the  waking  state, 
on  one  hand,  and  either  hypnosis  or  sleep  on 
the  other.  As  the  amount  of  dissociation 
which  accompanies  the  production  of  this 
state  is  neither  profound  nor  constant,  the 
submerged  memories  which  arise  are  not  com- 
plete, nor  are  they  consecutive.  Mainly  on 
this  account  ,the  results  obtained  with  this 
method  of  reproduction  of  forgotten  memories 
in  my  experience  have  not  been  as  satisfactory 
as  those  secured  with  hypnosis.  As  described 
by  Sidis,  the  mode  of  induction  of  the  hypnoidal 
state  is  as  follows: 

''The  patient  is  asked  to  close  his  eyes  and 
keep  as  quiet  as  possible,  without,  however, 
making  any  special  effort  to  put  himself  in 
such  a  state.  He  is  then  asked  to  attend  to 
some  stimulus,  such  as  reading  or  singing,  or 
to  the  monotonous  beats  of  a  metronome. 
When  the  reading  is  over,  the  patient  with  his 
eyes  shut  is  asked  to  repeat  it  and  tell  what 
comes  into  his  mind  during  the  reading,  or 
during  the  repetition,  or  immediately  after. 
This  should  be  carried  out  in  a  very  quiet 
place,  and  the  room,  if  possible,  should  be 
darkened  so  as  not  to  disturb  the  patient  and 
thus  bring  him  out  of  the  state  in  which  he  has 
been  put.  As  modifications  of  the  same 
method, — the  patient  or  subject  is  asked  to 
fixate   his   attention   on   some   object,   while   at 


Multiple   Personality  and  Amnesia     347 

the  same  time  listening  to  the  beats  of  a 
metronome,  the  patient's  eyes  are  then  closed, 
he  is  to  keep  very  quiet,  while  the  metronome  or 
some  other  monotonous  stimulus  is  continued. 
After  some  time,  when  the  patient's  respiration 
and  pulse  are  found  somewhat  lowered,  he 
is  asked  to  concentrate  his  attention  on  a  sub- 
ject closely  relating  to  the  symptoms  of  the 
malady  or  to  the  submerged  subconscious  state. 
In  other  words,  the  patient  is  in  a  hypnoidal 
state  favorable  for  the  emergence  of  subcon- 
scious experiences." 

''The  patient  again  may  be  asked  to  be  very 
quiet,  to  move,  or  to  change  position  as  little 
as  possible,  and  is  required  to  look  steadily 
into  a  glass  of  water  on  a  white  background 
with  a  light  shining  through  the  contents  of 
the  glass;  a  mechanism  producing  monotonous 
sounds  is  set  going,  and  after  a  time,  when  the 
patient  is  observed  to  have  become  unusually 
quiet,  he  is  asked  to  tell  what  he  thinks  in 
regard  to  his  sjnnptoms.  In  other  cases  it  is 
sufficient  to  put  the  patient  in  a  relaxed  condi- 
tion, have  his  eyes  shut  and  tell  him  to  think 
hard  of  the  particular  dissociated  states." 

"Now  in  working  with  the  method  of  hyp- 
noidization  I  have  often  observed  in  using  it 
that  the  patient  at  first  tries  to  concentrate  his 
attention  and  seems  to  fall  into  slight  hypnosis, 
but  pretty  soon  he  is  fully  awake.  In  closely 
watching  this  condition  I  found  that  at  first 


348  Psychopathology  of  Hysteria 

the  patient  attempted  to  fixate  his  attention, 
then  lost  control  over  it.  His  attention  being 
relaxed  he  fell  into  a  sleep-state,  out  of  which 
he  emerged  again,  owing  to  the  partial  presence 
of  the  idea  of  the  necessity  of  concentration  of 
the  attention,  as  well  as  to  the  partial  watch- 
fulness present.  It  is  this  alternate  and  incom- 
plete relaxation  and  concentration  of  the  atten- 
tion that  keeps  the  patient  on  the  borderland 
of  wakefulness,  hypnosis  and  sleep.  In  some 
cases  the  hypnoidal  state  passed  into  hypnosis. 
Thus  in  one  of  my  cases,  V.  F.,  at  first  I  ob- 
tained only  hypnoidal  states,  but  after  some 
time  the  hypnotic  state  gained  ground  and  the 
subject  passed  into  typical  hypnosis  and  finally 
into  a  somnambulistic  state.  In  other  cases  I 
have  observed  that  preliminary  to  the  passing 
into  the  hypnotic  state  proper  a  short  interval 
is  present  which  may  be  regarded  as  a  hyp- 
noidal condition.  In  many  other  cases  the 
patient  is  not  in  the  hypnoidal  condition,  but 
still  there  are  phemomena  present  which  re- 
mind one  strongly  of  the  hypnotic  state. "  (Jour, 
of  Abnormal  Psychology,  vol.  3,  p.  15.) 

With  a  limited  number  of  patients  dissociated 
memorjT-  complexes  can  be  reproduced  by  means 
of  crystal  vision  and  automatic  writing.  When 
one  suggests  to  a  hysteric  who  is  a  good 
visualizer  that  while  she  looks  into  a  crystal, 
or  some  other  object,  she  will  see  taking  place 
the   particular   event   of   which   one   may   hap- 


Multiple  Personality  and  Amnesia     349 

pen  to  be  desirous  of  obtaining  information, 
it  is  probable  that  the  suggested  visual  hal- 
lucinations will  occur.  Of  the  successful  ap- 
plication of  crystal  vision  in  the  Beauchamp 
case  one  instance  is  most  interesting  because  it 
demonstrates  the  conservation,  and  the  possibil- 
ity of  reproduction,  in  this  case  at  least,  of 
memories  of  events  which  happened  during 
febrile  delirium: 

"Miss  B.  looked  again  into  the  globe;  she 
saw  a  room  w^ith  a  bed  in  it.  There  w^as  a 
figure  in  the  bed;  the  figure  threw  off  the  bed- 
clothes and  got  up.  Miss  B.  exclaimed,  'Why, 
it  is  I!^  (Appeared  rather  frightened  at  what 
she  saw,  but  went  on  to  describe  it,  largely  in 
answer  to  my  promptings,  such  as,  ^Go  on,' 
'What  do  you  see?'  etc.).  She  saw  herself 
walking  to  and  fro,  up  and  dow^n  the  room. 
Then  she  climbed  on  to  the  window  sill  which  is 
the  deep  embrasure  of  a  mansard  roof.  Then 
she  climbed  outside  the  window  and  from  the 
sill  looked  dow^n  into  the  street.  It  was  night — 
the  street  lamps  were  lighted,  there  was  also 
the  gaslight  in  the  room.  As  she  looked  down, 
she  felt  dizzy.  Here  Miss  B.  turned  away 
frightened,  saying  she  felt  dizzy  as  if  she  were 
standing  there.  She  soon  continued.  She  saw 
her  vision-self  throw  into  the  street  below  an 
inkstand,  which  she  had  just  seen  herself  pick 
up  before  climbing  on  to  the  window  sill.  Miss 
B.  was  again  obliged  to  stop  looking  because 


350  Psychopathology  of  Hysteria 

of  dizziness.  After  a  time  she  returned  to  tlie 
globe.  She  saw  herself  go  back  into  the  room 
and  walk  np  and  down;  the  door  opened,  and 
she  jumped  into  bed  and  lay  quiet.  Miss  L. 
(a  friend)  entered,  went  out,  and  returned 
several  times ;  brought  a  poultice  which  she  put 
on  Miss  B.'s  chest;  Miss  B.  herself  remaining 
quiet.  Then  Miss  L.  went  out  and  Miss  B.  got 
up  and  took  the  poultice,  rolled  it  up  into  a 
little  bunch  and  hid  it  in  a  corner,  putting  a 
towel  over  it.     Here  the  experiment  ended."* 

''Miss  B.  stated,  on  being  questioned,  that 
she  could  not  remember  any  incident  like  the 
vision,  excepting  that  she  recognized  the  room 
as  the  first  one  she  occupied  when  she  came 
to  Boston  four  or  five  years  ago.    It  was  in  the 

top  story  of  a  house  on street;  she  was 

ill  there,  and  Miss  L.  took  care  of  her.  But 
she  did  not  remember  ever  having  climbed  on 
to  the  window,  or  having  thrown  an  inkstand, 
or  any  of  the  incidents  of  the  vision.  She  could 
throw  no  light  on  the  affair." 

''Deep  hypnosis:  B.  Ill  appeared.  With 
great  vivacity  and  amusement,  B.  Ill  ex- 
plained the  whole  scene.  'She'  had  pneumonia 
and  was  delirious;  and  'She'  imagined  'She* 
was  on  the  seashore  and  was  walking  up  and 
down  on  the  sand.    This  was  why  '  She '  walked 


*"Miss  L.,  a  physician,  has  confirmed  her  own  part 
in  this  scene  and  the  g'eneral  facts  of  the  illness  as 
she  knew  them.  Another  physician  had  diagnosed 
pneumonia." 


Multiple   Personality  and  Amnesia      351 

Tip  and  down  the  room,  and  *She^  stuck  her 
toes  in  the  carpet  thinking  it  was  sand.  There 
were  rocks  there,  and  the  window  sill  was  one 
of  them,  and  when  'She'  climbed  out  upon  the 
windoAv  sill  'She'  thought  'She'  was  climbing 
upon  a  rock,  and  'She'  took  up  a  stone,  as  'She' 
thought,  and  threw  it  into  the  sea.  This  was 
the  inkstand  that  'She'  threw  into  the  street. 
Then  when  'She''  took  the  poultice  and  hid  it 
in  the  corner,  'She'  thought  'She'  had  buried 
it  in  the  sand.  Ink  had  been  found  in  her 
shoes,  but  'She'  had  not  poured  ink  into  her 
shoes,  but  her  hand  shook,  and  'She'  had 
spilled  it  into  her  shoes.  Miss  L.,  seeing  the 
inkstains,  had  inferred  that  Miss  B.  had  poured 
the  ink  into  the  shoes,  and  had  told  Miss  B.  so. 
B.  Ill  was  highly  amused  at  all  the  mistakes  of 
Miss  B.'s  delirium."  (The  Dissociation  of  a 
Personality,  1906). 

The  method  of  association  reaction  time  ex- 
periments is  a  valuable  psychoanalytic  means 
whose  elaboration  we  owe  mainly  to  Jung,  and 
whose  interpretations  are  based  largely  upon 
the  theories  of  Freud.  The  clinical  application 
of  the  method  consists  in  timing  the  intervals 
between  stimulus  test  words,  which  are  called 
out  by  the  physician,  and  the  responses  of  the 
patient  with  the  associated  words  which  first 
arise  in  her  mind.  The  normal  reaction  time 
varies  somewhat  in  different  Individuals,  but 
the  average  is  about  one  or  two  seconds.      The 


352  Psychopathology  of  Hysteria 

physician  makes  up  a  list  of  about  one  hundred 
test  words  and  then  obtains  the  patient's  reac- 
tion time  to  each.  On  analyzing  the  results  it 
is  found  that  the  reaction  time  of  some  of  the 
tests  is  much  greater  than  the  patient's  aver- 
age— the  reaction  has  been  inhibited.  Careful 
study  of  these  "complex  indicators"  is  produc- 
tive of  a  certain  amount  of  information  con- 
cerning either  submerged  complexes  which  have 
been  "touched"  by  the  test  words,  or  conscious 
complexes  whose  existence  the  patient  does  not 
desire  to  reveal.  If  necessary  a  second  list  can 
be  analyzed  of  significant  words  which  the  re- 
sults of  the  first  experiment  suggest  to  the  phy- 
sician. 

Whenever  a  test  word  "touches"  a  hidden 
complex,  or  one  that  is  associated  with  a  strong 
feeling  tone,  the  reaction  time  is  much  length- 
ened, or  the  reaction  is  incomprehensible,  or  the 
patient  does  not  react  at  all,  and,  when  ques- 
tioned, asserts  that  she  has  forgotten  the  test 
word.  This  last  is  particularly  interesting  in 
that  it  illustrates  the  tendency  for  words  or 
ideas  which  have  become  associated  with  a  sub- 
merged complex  themselves  to  become  dissoci- 
ated. When  the  same  list  of  words  is  gone  over 
a  second  time  the  patient  usually  fails  to  react 
with  the  same  words  to  those  stimulus  words 
whose  reactions  were  inhibited  the  first  time. 
Often  significant  reactions  are  obtained  without 
retardation  of  the  reaction  time  providing  that 


Multiple  Personality  and  Amnesia     353 

the  complex  which  has  been  ''touched"  is  not 
submerged  nor  particularly  unpleasant.  On  the 
other  hand,  retardation  always  occurs  when  the 
patient  not  ^dshing  to  reveal  some  conscious  idea 
deliberately  substitutes  a  word  for  the  one  which 
arises  in  her  mind. 


CHAPTER   X 

Hysteric    Temperament — Suggestibility 
— Delusions — Insanity — Theories 

THE  mental  state  of  hysteric  persons 
usually  deviates  markedly  from  what 
might  be  considered  normal  standards, 
and  it  is  upon  this  continuous  patho- 
logic foundation  that  many  of  the  paroxysmal 
''accidents"  develop.  Strictly  speaking  it  is 
not  logical  to  speak  of  certain  selected  groups 
of  symptoms  as  the  mental  state  of  hysteria,  for 
the  study  of  the  disease  as  a  whole  is  merely  a 
study  of  morbid  mental  states  and  their  physi- 
cal expression.  Moreover,  there  is  no  group  of 
distinctive  mental  ''stigmata"  whose  detection 
enables  one  positively  to  pronounce  the  presence 
of  what  is  termed  hysteria,  or  by  reason  of 
whose  absence  hysteria  can  be  eliminated. 

By  no  means  do  all  hysterics  present  a  com- 
mon type  of  temperament.  In  the  same  man- 
ner that  the  character  of  all  other  symptoms 
depends  almost  entirely  upon  the  personal 
equation,  so  also  does  the  temi^erament  of  a 
hysteric.  The  mental  characteristics  of  a 
phlegmatic  German  who  develops  manifesta- 
tions of  hysteria  certainly  will  not  be  like  those 
of  an  emotional  Frenchman.  There  are,  never- 
theless,  certain   kinds   of  mental  peculiarities 

354 


Hysteric  Temperament  355 

which  are  encountered  so  frequently  among 
cases  of  hysteria  as  to  deserve  being  designated 
the  hysteric  temperament.  Though  possessing 
some  significance  when  present,  the  absence  of 
what  is  called  the  hysteric  temperament  is  not 
to  be  considered  as  evidence  of  any  value  in 
the  elimination  of  hysteria. 

Judgment  and  cerebral  inhibition  being  de- 
ficient, and  sensibility  to  many  kinds  of  im- 
pressions being  increased,  the  hysteric  is 
inclined  to  exhibit  imperfect  self-control  in  that 
her  reactions  to  mental  stresses  are  exag- 
gerated or  perverted.  Consequently,  emotional 
outbursts  may  occur  that,  according  to  usual 
standards,  are  excessive  in  character  and 
duration  and  which  normally  would  not  be 
justified  by  their  exciting  causes.  Briefly,  the 
reactions  of  the  individual  to  his  environment 
are  excessive  and  perverted. 

Emotional  instability  and  morbid  sensitive- 
ness naturally  result  in  rapid  variations  in 
moods:  at  one  moment  laughing,  the  hysteric 
may  be  crying  the  next.  The  same  factors  are 
apparent  in  the  ''hysterical"  attacks  of  alter- 
nate crying  and  laughing.  Not  all  emotional 
outbursts,  however,  are  significant  of  hysteria 
just  as  no  other  one  symptom  is  indicative  of 
the  disease,  and,  on  the  other  hand,  the  emotion- 
al displays  occurring  in  undoubted  hysteria 
should  not  be  considered  evidences  of  repre- 
hensible wilfulness.     Neither  are  they  always 


356  Psychopathology  of  Hysteria 

the  result  of  immediate  faulty  parental  super- 
vision; the  blame,  if  any,  should  rest  with  the 
decreased  power  of  inhibition  that  is  sympto- 
matic of  the  disease. 

In  hysteria,  the  faculty  of  mental  representa- 
tion is  greatly  increased  and  gives  rise,  among 
other  symptoms,  to  varying  moods  and  to 
romancing.  The  patient  passes  much  of  her 
time  in  weaving  stories  around  little  incidents 
that  arise,  and  usually  she  places  herself  in  the 
star  role.  If  the  faculty  of  visualization  is  well 
developed  these  day  dreams  are  visualized. 
One  patient  asserted  that  when  meditating  she 
heard  her  own  thoughts,  and  that  she  could 
hear  answering  voices  if  she  desired.  While 
romancing  she  visualized  the  scenes  of  her 
dramas  and  held  silent  conversations  with  the 
actors.  The  faculty  of  mental  representation 
being  so  highly  developed  in  those  who  are 
good  auditives  and  visualizers,  it  would  be 
interesting  to  know  the  frequency  with  which 
they  become  victims  of  hysteria  as  compared 
vnth  those  who  do  not  possess  these  powers. 
Indulgence  in  romancing  is  decidedly  harmful. 
Frequently,  not  only  delusions  and  other 
psychic  symptoms,  but  also  physical  projec- 
tions such  as  anaesthesia  and  paralysis  may  be 
traced  directly  to  some  day  dream  which  had 
supplied  the  material  that  subsequently  be- 
came fixed  by  unconscious  autosuggestion. 

Being   extremely   sensitive,   hysterics   brood 


Hysteric  Temperament  357 

over  supposed  wrongs,  neglect,  or  derision,  and 
often  some  of  their  complaints  seem  to  be  based 
upon  no  other  cause  than  morbid  desire  to 
provoke  attention  and  sympathy.  In  an  adult 
this  represents  reversion  to  similar  tendencies 
of  children.  After  being  rebuked,  or  spanked, 
often  the  child  tells  his  parents  that  they  don't 
care  for  him,  and  that  they  would  act  dif- 
ferently if  he  were  sick.  Going  off  by  himself, 
he  vividly  pictures  himself  seriously  ill  with 
his  friends  and  relatives  grouped  around  his 
bed  carefully  tending  to  his  wants,  grieving 
about  his  condition,  and  expressing  remorse  for 
their  former  neglect  and  ill  treatment.  The 
only  difference  between  these  day  dreams  of 
the  child  and  those  of  the  hysteric  depends 
upon  the  fact  that  in  the  latter  the  idea  of 
illness  is  sufficient  to  induce  actual  representa- 
tion. 

Morbid  desire  for  sympathy  and  to  be  the 
center  of  attention  is  a  prominent  trait  of  many 
hysteric  patients,  so  that,  excepting  as  subjects 
of  clinical  demonstration,  nothing  pleases  them 
more  than  to  be  carefully  examined  and 
studied  by  physicians.  So  great  may  become 
this  desire  that  the  hysteric  may  hesitate  at 
nothing  to  gratify  the  propensity.  Thus 
feigned  hagmatemesis,  anorexia,  fever,  and  self 
inflicted  mutilations  by  no  means  are  rare.  To 
reiterate,  such  malingering  should  not  be 
regarded  other  than  as  a  symptom,  and  as  such 


358  Psychopathology  of  Hysteria 

it  has  nothing  in  common  with  simulation  by  a 
non-hysteric. 

The  effects  of  desire  for  sympathy  and  atten- 
tion exhibited  by  one  of  Wilson's  cases  is  inter- 
esting. (Modern  French  Conceptions  of  Hys- 
teria, Brain,  1910,  p.  315.)  A  girl  of  15,  wish- 
ing ''to  be  coddled"  like  her  sister,  who  had  a 
deformed  foot  resulting  from  injury,  at  first 
unconsciously  copied  the  deformity  and  later 
drove  a  large  tack  into  her  foot  with  conse- 
quent infection  and  other  complications.  At  19 
she  cut  her  hand  in  order  to  make  the  school 
mistress  love  her  more.  The  following  year  the 
mother  was  ill  in  bed  and  this  aroused  in  the 
patient  the  desire  to  be  ill,  too,  and  to  receive 
sympathy.  Thinking  ''it  would  be  nice  to  have 
spinal  disease"  she  rubbed  nitric  acid  up  and 
down  her  back.  A  year  later  hysteric  para- 
plegia appeared  associated  with  analgesia  ex- 
tending up  to  the  waist  and  also  involving  the 
whole  of  one  side.  At  this  time  she  was  de- 
tected breakiug  off  needles  in  her  anaesthetic 
side. 

The  self  infliction  of  pain  in  McArthur's  case 
was  due  to  a  different  motive;  one  which  is  not 
rare,  but  which  is  seldom  carried  to  such  an 
extent.  (Jour,  of  Nervous  and  Mental  Disease, 
1911,  p.  425.)  When  17  the  patient  scratched 
the  end  of  her  little  finger  with  a  pin.  Recur- 
ring abscesses  followed,  and,  after  three  years, 
the  finger  was  amputated.      A  year   later  an- 


Hysteric  Temperament  359 

other  finger  became  similarly  involved,  and  this 
one,  in  its  turn,  was  amputated  at  the  end  of  a 
year.  After  this  the  other  fingers,  the  hand, 
and  segments  of  the  forearm,  and  arm  were 
sacrificed  progressively  for  recurrent  abscesses. 
Finally,  at  thirty-two,  even  the  scapula  and  the 
outer  half  of  the  clavicle  were  excised.  At  this 
time  Briquet  attacks  and  sensory  deficits  were 
present.  It  developed  that  pain  in  the  wound 
produced  an  orgasm,  and  for  this  reason  the 
patient  purposely  irritated  the  wound  and  pre- 
vented it  from  healing.  Psychoanalysis  of  this 
case  would  be  interesting  in  determining  how 
the  association  of  pain  and  orgasm  came  about 
originally. 

Egocentricity,  whether  this  be  active,  or  sim- 
ply a  passive  form  that  permits  the  patient  to 
accept  sacrifices,  frequently  results  from  desire 
to  command  sympathy  and  attention.  No  mat- 
ter how  altruistic  the  individual  may  have  been 
moderate  or  excessive  disregard  of  the  feelings 
and  rights  of  others  is  very  apt  to  develop  after 
the  onset  of  hysteria.  The  hysteric  malingerer 
does  not  seriously  concern  herself  about  the  addi- 
tional expense  that  her  simulation  may  impose 
upon  the  already  drained  finances  of  her  family ; 
neither  does  she  consider  the  long  hours  of  de- 
privation of  sleep  that  she  may  occasion  those 
who  are  caring  for  her  during  some  more  or  less 
grave  illness  which  she  is  simulating.  In  the 
words  of  Sidis  ^ '  innate  cussedness ' '  in  itself  may 
make  a  psychic  trouble  worth  studying. 


360  Psychopathology  of  Hysteria 

Often  the  patient  is  an  intelligent  woman 
whose  home  shows  abundant  evidence  of  refine- 
ment and  artistic  tastes.  Conversing  with  her 
we  note  that  she  is  quiet,  very  charming,  and 
that  she  possesses  a  widely  varied,  and  somewhat 
more  than  superficial,  fund  of  knowledge.  Really 
it  is  a  pleasure  to  chat  with  her.  Wlien  the  con- 
versation turns  to  herself,  and  particularly  to 
her  bodily  health,  she  continues  to  smile  pleas- 
antly while  describing  in  an  intelligent  manner 
her  various  symptoms,  for  each  of  which  she  has 
a  logical  explanation.  Touching  upon  her  his- 
tory she  volunteers  the  information  that  she  has 
never  been  hysterical  or  emotional;  in  fact  just 
the  reverse.  Protesting  all  the  while  about  any 
inconvenience  which  she  may  occasion  yet  she 
continues  to  detain  us  with  much  unnecessary 
and  irrelevant  detail.  Constantly  we  see  indi- 
cations that  while  apparently  she  strives  con- 
tinually to  be  most  considerate  of  others  still 
those  with  whom  she  is  associated  are  subjected 
to  much  inconvenience  and  unnecessary,  but 
willing,  self  sacrifice.  In  spite  of  what  ordi- 
narily would  be  considered  distressing  and  seri- 
ous manifestations  she  does  not  seem  to  be  con- 
cerned over  these.  Indeed,  they  afford  her  an 
opportunity  for  conversation  w^hich  is  just  as 
impersonal  as  if  she  were  discussing  the  health 
of  a  friend.  Such  a  patient,  one  whose  descrip- 
tion by  no  means  is  overdrawn  for  it  is  that  of 
an  actual  case,  is  typical  of  patients  encountered 
in  the  better  classes  of  society. 


Hysteric  Temperament  361 

In  the  sense  that  this  term  is  usuall/  em- 
ployed morbid  introspection  does  not  belong  to 
the  symptomatology  of  hysteria.  Rather  as  an 
evidence  of  the  clinical  syndrome  known  as 
psychasthenia  is  the  non-insane  obsessive  intro- 
spection. Neither  are  fear  and  worry  to  be  met 
with  in  the  infrequently  encountered  cases  of 
uncomplicated  hysteria.  The  typical  hysteric  is 
absolutely  unconcerned  about  her  condition,  no 
matter  how  serious  this  may  appear  to  be,  and 
the  only  reason  why  she  may  attend  to  her  symp- 
toms is  because  of  the  sympathy  and  attention 
which  they  may  provoke  in  others.  Instead  of 
worrying  over  their  condition  some  patients 
seem  almost  to  derive  pleasure  from  their  various 
manifestations.  These  are  the  confirmed  hys- 
terics who  delight  in  having  a  new  set  of  symp- 
toms or  in  presenting  aggravations  of  former 
ones  each  time  the  physician  calls.  Their  mal- 
ady is  superior  to  any  physician. 

It  is  difficult  to  hold  the  attention  of  a  hys- 
teric. Instead  of  attending  to  the  necessities 
of  the  moment  attention  is  diverted  into  other 
channels,  or  is  concentrated  upon  some  revery. 
This  characteristic  helps  to  explain  some  of  the 
inconsistencies  revealed  during  examination. 
When  testing  hearing  with  a  watch  the  ticking 
is  not  consciously  perceived  because  the  patient 
is  really  not  attending  to  the  perceptions. 
Frequently,  normal  persons,  who  have  not  been 
attending  to  what  has  been  said,  ask  that  a 


362  Psychopathology  of  Hysteria 

remark  be  repeated,  yet,  in  the  same  breath, 
they  show  that  they  have  heard  by  responding 
before  we  have  had  a  chance  to  comply  with 
the  request.  Unless  attention  is  deeply  con- 
centrated upon  some  one  object  normally  it  is 
possible  consciously  to  perceive  a  number  of 
different  kinds  of  sensory  impressions  while  at- 
tending to  a  variety  of  acts.  Thus  the  teacher 
lectures  to  his  class  while  demonstrating  manu- 
ally, ''keeping  an  eye"  on  the  delinquencies  of 
some  one  or  more  members,  and  perceiving  a 
number  of  other  extraneous  sensory  impres- 
sions. 

According  to  Janet  the  field  of  consciousness 
of  the  hysteric  is  so  contracted  that  she  is 
unable  to  attend  to  different  impressions  and 
acts  at  the  same  time.  Although  Janet's  views 
of  retraction  of  the  field  of  consciousness  cannot 
be  accepted  in  their  entirety,  yet  many  of 
the  manifestations  of  hysteria  closely  resem- 
ble peculiarities  of  normal  absent-mindedness. 
Does  not  the  absent-minded  individual  ignore 
all  perceptions  unrelated  to  the  absorbing  in- 
terest of  the  moment?  According  to  Ribot, 
voluntary  or  artificial  attention  is  a  product 
of  education — of  civilization — and  it  is  grafted 
upon  spontaneous  or  natural  attention.  (The 
Psychology  of  Attention,  Open  Court  Pub.  Co., 
1890.)  Hence  we  may  look  upon  the  hysteric's 
deficiency  of  voluntary  attention  as  one  of  the 
many  types  of  reversion,  exhibited  in  hysteria, 


Hysteric  Temperament  363 

towards    the   mental   traits   of   the    child,    or, 
phylogenetically,  towards  those  of  the  savage. 

In  addition  to  instability  of  attention  the 
hysteric  exhibits  a  tendency  towards  inter- 
ference with,  or  unconscious  prevention  of, 
more  or  less  automatic  acts  when  her  attention 
is  directed  to  the  manner  in  which  they  are 
performed.  This  is  but  an  exaggeration  of  the 
normal,  for  most  of  our  acquired  reflex  or  auto- 
matic actions  are  best  executed  unconsciously. 
The  normal  interference  of  conscious  attention 
is  often  to  be  observed  in  the  gait  of  the 
student  as  he  ascends  the  steps  to  the  stage  in 
order  to  receive  his  diploma,  and  is  often  appar- 
ent in  the  actions  of  the  actor  new  to  the  stage. 
This  fact  is  so  well  known  that  even  the  lay- 
man remarks  that  the  individual  is  self-con- 
scious. It  is  shown  also,  as  Jastrow  has  re- 
marked, by  the  difficulty  which  many  experi- 
ence in  4he  attempt  to  swallow  a  pill.  Al- 
though those  conditions  which  are  called  atten- 
tion neuroses — stammering,  insomnia,  astasia- 
abasia,  attention  tremors,  etc. — may  occur  in 
hysteria  the  majority  are  symptomatic  of 
psychasthenia. 

Volition  is  not  impaired  in  hysteria;  it  is 
perverted.  The  patient  is  unable  consciously 
to  will  a  paralyzed  arm  to  move  because  sub- 
consciously a  greater  effort  of  volition  is  exer- 
cised in  order  to  maintain  the  paralysis.  Let 
us    regard    the    apparent    diminution    of    will 


364  Psychopathology  of  Hysteria 

power  as  being  due  to  the  antagonistic  effects 
of  contrary  and  subconscious  acts  of  volition. 
Instead  of  being  decreased  it  would  seem,  in 
fact,  that  there  occurs  actual  increase  of  will 
power.  Surely  it  requires  an  unusual  amount 
of  perverse  application  of  the  will  in  order  that 
deliberate  mutilations  can  be  self  inflicted  for 
no  other  reason  than  to  elicit  sympathy  and 
attention.  Consider,  too,  the  intensity  of  pur- 
pose necessary  to  starve  oneself  to  death  as  so 
frequently  occurred  consciously  in  cases  of 
hysteric  simulation  of  anorexia,  and  subcon- 
sciously in  the  essential,  non-simulated  ano- 
rexias of  hysteria. 

Abnormal  Suggestibility.  The  only  con- 
stant, and  therefore  characteristic,  symptom 
or  stigma  of  hysteria,  the  one  which,  in  reality, 
is  at  the  foundation  of  the  great  majority  of 
other  manifestations,  is  abnormal  increase  in 
susceptibility  to  suggestion,  whether  this  be  to 
the  suggestions  of  others  or  of  self.  Just  as  it 
is  believed  that  the  ultimate  analysis  of  thought 
and  of  all  other  forms  of  mental  activity  re- 
veals the  dependency  of  these  processes  upon 
sensory  impressions — immediate  or  remote — so 
that  which  is  designated  autosuggestion  must  be 
consequent  upon  an  external  stimulus.  Clinically 
the  source  of  the  autosuggestions  of  hysterics 
often  is  found  to  be  the  unintentional  sugges- 
tions of  others.  Thus  the  autosuggestion 
responsible  for  psychic  contagion  is  really  a 
manifestation  of  heterosuggestion. 


Hysteric  Temperament  365 

Expectant  attention  is  the  equivalent  of 
autosuggestion.  If  one  attends  to  any  function 
while  expecting  certain  variations  to  occur,  is 
not  autosuggestion  implied?  By  autosuggestion 
we  do  not  mean  that  in  the  absence  of  some 
good  reason  a  patient  deliberately  thinks:  ''My 
arm  will  become  paralyzed."  Rather  than 
such  a  gross  misinterpretation  of  the  term  as 
applied  to  the  genesis  of  symptoms  of  hysteria, 
let  us  say  that  there  is  subconscious  belief, 
engendered  hy  more  or  less  logical  reasoning, 
that  the  arm  may  become  paralyzed.  In  a 
hj^steric  patient  the  idea  of  a  symptom  only  too 
readily  is  evoked,  and  the  process  by  which 
actual  representation  occurs  through  the 
agency  of  these  ideas  is  designated  autosugges- 
tion. To  those  who  have  not  experimented 
with  hypnosis — and  practical  knowledge  of  the 
phenomena  capable  of  being  brought  about  by 
suggestion  is  almost  essential  in  order  to  grasp 
the  mechanism  of  production  of  symptoms  of 
hysteria — free  use  of  the  term  autosuggestion 
is  apt  to  convey  the  impression  that  the  process 
is  mysterious,  and  but  little  understood,  and 
that  the  term  is  too  comprehensive;  in  fact, 
that  it  is  but  a  convenient  cloak  for  real  ignor- 
ance of  the  mechanism  which  is  being  described. 

For  the  purpose  of  illustrating  the  quite 
reasonable  manner  in  which  an  autosuggestion 
is  originated,  there  is  no  better  example  than 
that  afforded  by  the  use  of  a  prism  in  a  case  of 


366  Psychopathology  of  Hysteria 

suggested  visual  hallucination.  When  a  prism 
is  placed  before  one  eye  of  a  subject  in  whom 
one  has  succeeded  in  producing  by  suggestion 
a  visual  hallucination,  not  only  are  the  images 
of  actual  objects  doubled,  but  also  the  hal- 
lucinatory image  is  reduplicated.  Such  an  ex- 
periment reveals  the  delicacy  of  autosugges- 
tion. To  call  the  process  by  which  this  re- 
duplication occurs  autosuggestion  is  just  as 
gross  a  means  of  explanation  as  to  apply  the 
same  term  to  similar  processes  occurring  con- 
stantly in  hysteria.  The  fault  lies  in  the  im- 
possibility to  designate  briefly  a  process  which 
is  so  complex  and  so  delicate  as  that  of  auto- 
suggestion, but  to  one  who  is  conversant  with 
hypnotic  suggestion  the  term  autosuggestion 
is  quite  intelligible. 

It  has  been  contended  that  the  ' '  suggestion- 
ists''  attempt  to  explain  everything  by  sugges- 
tion without  being  able  to  explain  suggestion 
itself.  Neither  can  physicists  tell  us  just  what 
electricity  is,  yet  they  manage  to  understand 
it  sufficiently  to  enable  others  to  make  use  of 
its  advantages.  As  we  do  possess  knowledge  of 
the  effects  of  intentional  suggestion  in  hypnosis 
and  hysteria,  there  does  not  seem  to  be  any 
reasonable  objection  to  descriptions  of  the  pa- 
thogenic effects  of  accidental  suggestion  in  those 
who  are  known  to  be  abnormally  susceptible  to 
this  agent,  even  though  we  cannot  tell  just  what 
it  is  or  how  it  acts. 


Hysteric  Temperament  367 

To  understand  better  the  pathogenic  possi- 
bilities of  suggestion,  let  us  digress  in  order 
briefly  to  study  normal  suggestibility;  for  all 
people  are  susceptible  to  suggestion  of  some 
form  or  other,  even  though  habitually  they  may 
seem  to  exhibit  opposition  to  external  influ- 
ences. The  great  numbers  who  developed 
manifestations  of  hysteria  among  those  who 
attended  the  early  religious  revivals,  and 
among  Indians  during  ghost  dances,  is  indica- 
tive of  the  suggestibility  of  mankind.  Among 
many  other  similar  instances  which  could  be 
adduced  in  reference  to  the  heightened 
suggestibility  characteristic  of  a  mob  is  one 
related  by  De  Goncourt:  During  the  Franco- 
Prussian  war,  thousands  of  men  were  convinced 
that  they  had  seen  posted  on  a  pillar  of  the 
Paris  Bourse  an  announcement  of  French 
victories — some  even  had  read  the  bulletin — 
when,  in  reality,  the  incident  was  one  of  a 
mutually  suggested  visual  hallucination. 

Normally,  a  suggestion  tends  irresistibly  to 
arouse  ideation  in  the  same  manner  that  all 
thought  is  dependent  upon  present  or  former 
sensory  impressions.  Just  as  emotions  always 
find  expression  in  some  form  of  physical 
activity,  so  man  tends  to  act  in  accordance 
with  his  ideas.  It  follows,  then,  that  sugges- 
tions are  disposed  to  become  realized.  To  con- 
trol this  tendency,  cerebral  inhibition  is 
brought  into  play — the  suggested  idea  is  criti- 


368  Psychopathology  of  Hysteria 

cally  examined,  and  if  not  compatible  with  the 
interests  of  the  individual,  the  suggestion  is  not 
acted  upon.  Confidence,  on  the  other  hand, 
leads  to  inhibition  of  criticism.  Even  though 
contrary  to  our  own  convictions,  we  often 
accept  and  carry  out  the  suggestions  of  another 
who  possesses  our  confidence.  Thus,  we  are 
not  constantly  on  the  defensive  when  obtaining 
information  from  those  in  whom  we  have 
confidence;  while,  on  the  contrary,  we  refuse 
to  believe  all  the  statements  of  one  whom  we 
distrust,  especially  if  critical  examination  of  his 
assertions  results  in  doubt  concerning  their 
probability.  Confidence,  then,  increases  sug- 
gestibility, and  distrust  inhibits  this  normal 
characteristic  of  the  human  mind. 

Children  are  highly  suggestible  because  they 
do  not  possess  sufficient  knowledge  to  enable 
them  to  examine  critically  suggested  ideas 
before  accepting  them  as  facts.  They  have 
confidence  in  most  everyone  because  they  have 
not  yet  learned  that  much  of  our  vaunted 
knowledge,  and  much  of  what  is  taught  them 
as  facts,  later  must  be  subjected  to  critical 
revision  or  entirely  discarded.  In  fact,  anyone 
who  is  ignorant  of  a  subject  necessarily  must 
accept  the  statements  of  one  who  knows  more 
than  he  about  the  matter.  The  student  would 
only  be  confused  were  his  teacher  to  qualify 
his  statements  and  to  discourse  learnedly  on 
theories    and    exceptions.      Hence   he   is    given 


Hysteric  Temperament  369 

a  skeleton  of  dogmatic  facts.  After  he  has 
acquired  rudimentary  knowledge  of  the  sub- 
ject, the  student  discovers  that  he  must  discard 
some  of  these  fundaments,  and  so  elaborate  the 
revised  whole  that  finally  he  possesses  a  con- 
ception which  is  largely  the  product  of  his  own 
efforts. 

Because  of  their  confidence,  and  being 
unaccustomed  to  subject  to  criticism  what  they 
are  told,  children  may  accept  the  most  improb- 
able statements.  So  readily  does  the  imagin- 
ative child  confuse  his  own  day  dreams  with 
reality  that  it  is  not  surprising  that  another 
person  unintentionally  may  cause  him  to  be 
the  victim  of  hallucinations  and  delusions.  On 
more  than  one  occasion  a  child  has  testified 
about  some  crime  when  his  testimony  was 
solely  the  result  of  a  suggestive  form  of  ques- 
tioning, or  of  a  "third  degree'^  examination. 
It  is  not  unknown,  also,  for  false  confessions  of 
crimes  to  be  obtained  in  the  same  manner — 
even  with  adults — and  with  most  disastrous 
consequences. 

The  combative,  self-reliant  man  who  takes 
pride  in  asserting  that  he  is  not  open  to  the 
influence  of  others  is  actually  less  suggestible 
than  usual.  Still,  even  he  can  be  successfully 
acted  upon  with  suggestion,  providing  that  he 
is  unaware  of  the  fact.  What  might  be  called 
a  general  law  of  suggestibility  provides  that 
normally,    and    often    abnormally,    the    more 


370  Psychopathology  of  Hysteria 

veiled  and  indirect  the  suggestion  the  greater 
the  chance  of  realization,  while  during  hyp- 
nosis, and  in  some  cases  of  hysteria,  usually 
the  more  direct  and  forcible  the  suggestion  the 
more  apt  is  it  to  be  accepted.  In  other  words, 
normally  a  suggestion  which  is  recognized  as 
such  always  tends  to  arouse  opposition.  If 
one  should  remark  to  a  hysteric:  ''Your  arm 
is  paralyzed  and  without  feeling, ''  it  is  prob- 
able that  she  would  deny  the  assertion  at  once. 
But  subject  the  same  patient  to  the  usual 
suggestive  form  of  physical  examination  which 
reveals  to  her  that  the  physician  expects  to  find 
loss  of  sensibility  as  part  of  her  disease,  and 
commonly  angesthesia  will  be  discovered  at  the 
time,  or  afterwards. 

Spontaneously  in  psychasthenia,  and  often 
artificially  as  a  result  of  hypnotic  suggestion, 
there  may  be  strenuous  opposition  to  a  sug- 
gested idea,  yet  the  conscious  rebellion  is  over- 
come by  subconscious  acceptance.  It  is  char- 
acteristic of  a  psychasthenic  to  be  fighting  con- 
tinually against  obsessions.  While  walking 
along  the  street  a  psychasthenic  sees  a  fruit 
stand  and  the  thought  flashes  into  his  mind  of 
the  shocking  consequences  which  would  ensue 
were  he  caught  stealing  an  orange.  Though 
the  fear  of  stealing  an  orange  and  the  impul- 
sion to  do  so  are  recognized  as  foolish,  yet,  as 
much  as  he  strives,  he  cannot  dismiss  these 
obsessions  from  his  mind.     The  resistance  of  the 


Hysteric  Temperament  371 

psychasthenic  to  his  obsessions  is  due  to 
knowledge  concerning  the  source  and  nature  of 
his  symptoms.  On  the  other  hand,  the  hysteric 
is  unaware  of  the  reason  for  her  symptoms  be- 
cause the  whole  mechanism  is  subconscious. 
The  difference  between  the  two  is  well  illus- 
trated by  the  difference  in  the  manner  of  ful- 
fillment of  a  post-hypnotic  suggestion  which  the 
patient  recognizes  as  such,  and  of  one  w^hose 
source  is  veiled  by  amnesia. 

What  is  suggestion?  The  definition  of  such 
a  comprehensive  word  is  as  impossible  as  the 
definition  of  hysteria.  The  whole  question  of 
suggestion  resolves  itself  into  the  necessity  for 
each  to  have  his  own  conception  just  as  all  who 
have  dealt  with  the  subconscious  have  their 
own  useful  but  widely  varying  conceptions  of 
the  subject.  Bernheim  comprehensively  de- 
fines suggestion  as  the  act  by  which  an  idea  is 
awakened  and  accepted.  Sidis  writes:  "By 
suggestion  is  meant  the  intrusion  into  the  mind 
of  an  idea ;  met  with  more  or  less  opposition  by 
the  person ;  accepted  uncritically  at  last ;  and 
realized  unreflectively,  almost  automatically." 
(Psychology  of  Suggestion,  1889,  p.  15.)  Mere- 
ly as  a  working  hypothesis  let  us  say  that  nor- 
mal suggestibility  consists  in  the  critical  ac- 
ceptance of  suggested  ideas  providing  that  they 
promote,  or  are  compatible  with,  the  welfare  of 
the  individual.  A  state  of  abnormal  suggesti- 
bility is  in  evidence  when  by  reason  of  an  ex- 


372  Psychopathology  of  Hysteria 

cessive  amount  of  confidence,  or  of  diminution 
in  the  power  critically  to  examine  and  to  reject 
what  is  suggested,  a  person  accepts  and  acts 
upon  ideas  which  do  not  conserve  his  own 
interests. 

A  good  example  of  the  genesis  of  a  symptom 
in  the  suggestion  of  another  is  shown  by  a 
patient  who,  in  addition  to  other  symptoms. 
for  several  years  had  been  afraid  to  go  to 
sleep.  The  origin  of  the  fear  was  unknown 
to  her,  yet  it  was  found,  during  hypnosis,  that 
following  the  sudden  death  of  her  father  a 
"clairvoyant"  friend  in  whom  she  had  im- 
plicit faith  had  told  her  to  take  good  care 
of  herself  as  her  turn  was  coming  soon.  The 
shock  of  her  father  ^s  death  being  a  good 
foundation,  this  suggestion  became  fixed,  and 
before  a  month  had  passed  she  developed 
"nervous  prostration"  and  was  confined  to  bed 
for  a  few  weeks.  Her  fear  of  going  to  sleep 
was  based  upon  fear  that  she  would  not  wake 
in  the  morning. 

Princess  Beauchamp  and  B.  C.  A.  cases  con- 
tain many  examples  of  the  mechanism  of  auto- 
suggestion in  the  production  of  various  mani- 
festations. In  the  section  dealing  with  astasia- 
abasia  one  instance  already  has  been  men- 
tioned. The  following  one  is  described  by  the 
co-conscious  personality  B.  of  the  B.  C.  A.  case: 
"C.  once  had  a  visual  hallucination  of  Dr. 
Prince,  because  I  was  thinking  of  him.     She 


Hysteric  Temperament  373 

was  thinking  of  entirely  different  matters,  but 
I  was  thinking  that  if  it  were  not  for  Dr. 
Prince  I  might,  perhaps,  stay  all  the  time,  and 
was  wondering  why  it  was  that  I  did  not  go 
away  somewhere ;  why  it  was  that  I  felt  bound 
to  keep  C.'s  appointments  with  him,  etc.  As  I 
was  thinking  all  this  C.  suddenly  saw  Dr. 
Prince  standing  before  her.  He  was  so  real 
that  she  spoke  his  name,  saying,  'Why,  Dr. 
Prince!'  "  (Jour,  of  Abnormal  Psychol.,  vol.  3, 
p.  311). 

Hallucinations^  Delusions,  Sub-conscious 
Fabrication.  By  reason  of  the  increased  power 
of  mental  representation,  hallucinations,  delu- 
sions and  subconscious  fabrication  are  exceed- 
ingly common  in  hysteria.  Even  during  the 
minor  emotional  crises  hallucinations  not  only 
occur,  but  their  character  determines  largely 
the  nature  of  the  attack.  Thus  Sallie  S.  hal- 
lucinates her  dead  child  during  her  seizures,  and 
Parker's  patient  experiences  a  fetid  taste  before 
each  convulsive  attack. 

Through  the  agency  of  hypnotic  suggestion 
it  is  not  difficult  to  induce  hallucinations  either 
during  the  hypnotic  state,  or  after  resumption 
of  the  usual  state  of  consciousness.  Ordinarily 
those  in  whom  hypnotic  hallucinations  can  best 
be  secured  are  the  good  visualizers  or  auditives. 
Otherwise  the  subject  states  that  the  music 
runs  through  his  head,  but  he  doesn't  actually 
hear  it,  or  that  the  picture  only  rises  in  his 


374  Psychopathology  of  Hysteria 

mind.  The  successfully  induced  hallucination 
corresponds  to  those  of  hysteria  while  the  less 
successful  ones  resemble  the  mental  imagery  of 
the  good  visualizer  who  can  project  the  mental 
image  of  a  person  and  make  the  projected 
image  act  as  desired,  but  who  recognizes  that 
the  image  is  only  the  product  of  his  own  mind. 

What  has  been  called  a  negative  hallucination 
is  the  absence  of  conscious  perception  of  what 
subconsciously  is  perceived.  Hysteric  amauro- 
sis and  other  varieties  of  disturbances  due  to 
lack  of  conscious  perception  of  sensory  impres- 
sions, particularly  when  the  deficit  is  systema- 
tized, furnish  examples  of  this  condition. 

When  the  memory  of  the  hallucinations  or 
delusions  of  a  hysteric  crisis,  or  of  some  other 
state  of  alteration  of  consciousness,  is  carried 
over  to  the  usual  state  and  the  patient  relates 
the  subjective  experiences  as  actual  occurrences 
the  condition  is  known  as  subconscious  fabrica- 
tion. A  common  source  of  subconscious  fabrica- 
tion is  the  day  dream.  So  vivid  may  be  the 
mental  imagery  of  the  day  dream  that  its  con- 
tent may  become  fixed  and  elaborated  in  the 
same  manner  that  the  habitual  liar  finally  be- 
lieves his  own  lies.  Whatever  the  origin,  the 
patient  really  believes  in  his  fabrications  and  he 
relates  them  without  having  any  intention  to  de- 
ceive. It  is  unfortunate,  however,  that  generally 
the  fabrications  are  looked  upon  as  intentional 
lies,  and  it  is  on  this  account  that  the  hysteric  is 


Hysteric  Temperament  375 

supposed  to  be  deceitful  and  thoroughly  unre- 
liable. 

On  two  occasions  one  young  hysteric  dreamed 
that  two  men  had  entered  her  room  and  had 
cut  off  her  hair.  The  third  morning  her  window 
was  found  open  and  her  hair,  cut  off  about  six 
inches  from  the  scalp,  was  discovered  on  the 
floor.  She  told  the  family  and  myself  that  she 
did  not  know  how  her  hair  had  been  cut  off,  but 
that  she  thought  someone  must  have  entered  her 
room  during  the  night.  During  the  hypnotic 
state  she  admitted,  without  any  hesitation,  hav- 
ing cut  off  her  hair  because  she  did  not  like  it 
so  long.  Formerly  the  hair  had  been  cut  every 
summer,  but  this  year,  in  spite  of  her  remon- 
strances, it  had  not  been  done.  Dreams  being 
largely  based  upon  antecedent  events  and 
thoughts,  it  is  not  surprising  that  after  unsat- 
isfactory discussions  over  having  her  hair  cut 
the  little  girl  should  have  experienced  dreams  in 
which  her  desire  was  fulfilled.  The  dreams  prob- 
ably acted  as  suggestions  and  as  reinforcements 
to  her  desire  with  the  result  that  she  got  up  at 
night  and  cut  off  her  hair.  Being  in  a  somnam- 
bulistic condition  at  the  time  she  did  not  remem- 
ber after  waking  in  the  morning  what  had 
occurred.  Consequently,  she  drew  upon  her 
memories  of  the  former  dreams  in  order  to  ex- 
plain the  event. 

Suppose  that  while  romancing  a  patient  appro- 
priates  and   applies   to   herself   some   incident 


376  Psychopathology  of  Hysteria 

which  happened  to  a  friend.  Later  she  may 
relate  the  exaggerated  occurrence  as  having 
happened  to  herself.  Gordon  has  reported  a  case 
in  which  the  patient  acted  in  accordance  with 
the  belief  that  her  relatives  were  trying  to  kill 
her.  These  persecutory  delusions  were  the  out- 
come of  a  novel  which  she  had  read.  On  an- 
other occasion  she  recounted  with  a  wealth  of 
detail  the  events  of  her  marriage  and  honeymoon 
abroad.  This  fabrication,  too,  was  the  result  of 
personal  application  of  material  derived  from 
another  novel.  (Amer.  Jour,  of  the  Med.  Sci- 
ences, 1906,  1,830.) 

In  a  case  of  dissociation  of  the  personality 
recorded  by  Angell,  the  patient  narrated  the  most 
remarkable  and  elaborate  history  of  periods  for 
which,  in  reality,  he  was  amnesic.  Afterwards 
it  was  found  that  his  account  was  due  to  falsi- 
fication of  memory;  the  patient  really  believing 
at  the  time  what  he  related.  This  patient  filled 
in  the  gaps  in  his  memory  with  elaborate  detail 
just  as  a  subject  who  has  carried  out  a  post- 
hypnotic suggestion  gives  a  specious  reason  for 
the  act  which  he  affirms  was  performed  of  his 
' '  own  free  will. ' '  When  hysteric  patients  relate 
improbable  tales,  or  ones  which  are  known  to  be 
untrue,  one  must  not  be  mislead  into  believing 
that  the  stories  represent  deliberate  lying  whose 
object  is  to  stimulate  interest  and  wonder. 

Hysteric  Insanity.  There  is  still  less  of  a 
dividing  line    between    ordinary    hysteria  and 


Hysteric  Temperament  377 

what  is  termed  hysteric  insanity  than  there  is 
between  sanity  and  insanity. 

Whether  one  decides  that  a  case  is  one  of 
hysteria  or  of  hysteric  insanity  depends  entirely 
upon  the  intensity  and  fixity  of  the  more  obvious 
psychic  manifestations,  and  upon  the  degree  to 
which  they  incapacitate  the  patient  from  enter- 
ing into  external  relations. 

As  a  matter  of  fact  the  majority  of  hysteric 
patients  present  many  of  the  symptoms  upon 
which  a  diagnosis  of  insanity  is  ordinarily  based. 
Thus  transitory  hallucinations,  delusions,  and 
states  of  delirium  and  of  confusion  are  exceed- 
ingly common.  Leaving  out  of  consideration  the 
possibility  of  insanity  plus  manifestations  of 
hysteria,  if  one  chooses  to  recognize  such  a  com- 
bination, then  there  really  is  no  such  condition 
as  hysteric  insanity  just  as  hysteric  paralysis  is 
not  actual  paralysis;  either  of  these  manifesta- 
tions being  merely  a  psychic  duplication  of  more 
serious  conditions.  All  the  clinical  types  of 
insanity,  however,  may  be  counterfeited  so  ver- 
itably that  often  a  mistake  in  diagnosis  may  be 
made  and  remain  uncorrected  until  the  patient 
has  been  under  observation  for  a  considerable 
period — perhaps  in  a  hospital  for  the  insane. 

On  one  occasion  I  signed  the  commitment 
papers  of  a  young  girl  who  presented  what 
were  considered  to  be  indubitable  manifesta- 
tions of  alienation,  only  to  have  her  discharged 
over  two  months  later  with  the  report  that  dur- 


378  Psychopathology  of  Hysteria 

ing  the  whole  of  her  stay  in  the  institution  she 
had  been  entirely  free  from  any  symptoms  of 
insanity.  Until  her  admission  to  the  hospital 
this  patient,  nevertheless,  had  exhibited  many 
fixed  delusions  of  a  paranoid  type.  Frequently 
she  had  threatened  to  kill  her  father,  to  set  fi^re 
to  the  house,  and  to  commit  suicide.  On  two 
occasions  she  had  attempted  suicide  with  gas. 
Moreover  there  was  good  reason  to  believe  that 
she  had  entertained  homosexual  relations  with 
her  sister.  In  consequence  of  fear  that  the  pa- 
tient would  commit  some  serious  act  of  violence 
after  her  release  from  the  hospital,  her  parents 
refused  to  allow  her  to  remain  at  home  so  she 
was  admitted  to  a  charitable  institution. 

It  must  not  be  thought  that  patients  with 
hysteric  insanity  do  not  become  violent,  for 
such  is  not  the  case.  In  a  comprehensive  paper 
containing  reports  of  a  large  number  of  eases 
of  hysteric  insanity  Woodman  (Jour,  of  Nerv. 
and  Ment.  Dis.,  Jan.,  Feb.,  and  Mar.,  1908.) 
remarks :  ' '  On  the  other  hand  the  symptoms 
are  of  wide  variety  and  may  be  of  extreme 
violence.  It  is  a  mistake  to  think  that  because 
a  patient  is  hysterical  that  all  the  mental 
symptoms  are  shallow  and  ephemeral  and 
scarcely  are  real  at  all.  A  hysteric  often  acts 
under  profound  emotion  and  may  do  any  rash 
or  violent  act  that  profound  emotion  suggests, 
as  for  example,  Case  No.  5,  in  the  present  series, 
took  with  suicidal  intent  all  her  sleeping  pow- 


Hysteric  Temperament  379 

ders  at  once,  and  recovered  because  the  total 
dose  was  not  lethal  rather  than  because  her 
suicidal  act  was  consciously  inadequate.  More 
or  less  determined  and  entirely  real  efforts  at 
suicide  are  decidedly  common." 

As  illustrated  by  the  Bachman  case  even 
murder  may  be  committed  during  hysteric  in- 
sanity. This  case  being  so  unusual  and  so  in- 
structive a  somewhat  detailed  account  seems 
warranted.  Following  a  period  of  careful  study 
of  the  Bible,  at  the  instigation  of  a  friend  who 
had  recently  been  converted,  Bachman  de- 
veloped a  state  of  religious  ecstasy  with  visions. 
Through  psychic  contagion  his  wife,  sister, 
and  brother-in-law  became  similarly  affected. 
Among  the  phenomena  experienced  by  this 
small  group  of  worshippers  who  made  their 
own  interpretations  of  the  New  Testament, 
were  the  ''second  coming  of  Christ,"  and  the 
expulsion  of  devils  from  their  bodies  by  the 
Spirit  of  God. 

During  the  height  of  religious  frenzy  ac- 
companying the  efforts  of  casting  out  of  devils 
Bachman  killed  his  five-year-old  niece.  This 
act  was  the  consequence,  he  stated,  of  impul- 
sions, which  he  felt  came  from  God,  to  kill  the 
child,  thus  driving  out  the  devils  and  sending 
her  to  heaven  instead  of  to  hell. 

Three  weeks  after  the  tragedy  he  related  the 
facts  of  the  murder  without  hesitancy  or 
emotional  display  except  for  slight  exaltation 


380  Psychopathology  of  Hysteria 

when  discussing  his  religions  views.  The  only 
regret  he  had  was  that  the  others  had  aban- 
doned the  new  creed.  Having  been  declared 
insane  by  a  commission  in  lunacy  he  was  ad- 
mitted to  the  State  Hospital  for  the  Insane  at 
Norristown.  Not  until  eight  months  after  the 
deed  did  he  show  any  change  in  his  views,  and 
then  with  distinct  emotion  he  talked  of  the 
crime  stating  that  he  must  have  been  influenced 
by  a  higher  power. 

''In  a  conversation  held  nearly  a  year  after 
the  ones  above  reported,"  writes  W.  W.  Rich- 
ardson, the  author  of  the  paper  of  which  the 
above  account  is  an  abstract,  (The  Case  of 
Robert  Bachman,  Jour,  of  Nervous  and  Mental 
Diseases,  1910,  p.  689.)  ''he  stated  that  he  and 
his  wife  had  lived  in  a  very  narrow  circle  all 
their  lives  and  that  he  had  never  realized  how 
ignorant  they  were  of  life  and  the  relations  of 
things  until  he  came  to  Norristown.  He  said 
he  had  known  nothing  of  insanity  nor  what 
insane  people  were  like.  Since  coming  here  he 
had  had  much  opportunity  to  learn  what  in- 
sanity meant  and  to  compare  himself  with 
others  whom  he  knew  to  be  insane.  While  he 
still  felt  that  his  act  was  not  wrong  for  the 
reason  that  his  motives  were  pure  and  that  he 
had  no  evil  thoughts  against  the  child,  still  he 
tacitly  admitted  the  probability  that  he  was  not 
mentally  sound  when  he  killed  the  child.  At 
this  conversation  it  was  noted  also  that  he  was 


Hysteric  Temperament  381 

under  a  considerable  emotional  strain  and  that 
he  felt  the  subject  a  painful  one,  thus  shomng 
a  striking  contrast  to  his  early  readiness  of 
speech  about  the  matter." 

' '  Since  his  admission  to  the  institution  he  has 
been  a  model  patient  in  every  respect,  working 
faithfully  and  efficiently  wherever  placed  and 
showing  much  enjoyment  in  the  day's  work, 
•especially  when  out-of-doors  or  about  ma- 
chinery, for  which  he  has  an  aptitude.  He  is 
extremely  tactful  and  courteous  in  all  his  rela- 
tions with  both  patients  and  officials.  He  never 
discusses  his  troubles  with  anyone  unless  ques- 
tioned and  then  only  with  physicians." 

The  ^vriter  believes  that  there  are  many  rea- 
sons why  Bachman  should  not  be  considered  a 
religious  paranoiac.  He  considers  the  diagnosis 
difficult  but  concludes  that  "in  view  of  the 
epidemic  nature  of  the  whole  manifestation,  the 
absence  of  delusions  at  present  and  the  tend- 
ency toward  recovery  of  a  normal  mental  tone, 
a  diagnosis  of  h^^sterical  insanity  of  the  epi- 
demic type  seems  the  only  one  justifiable." 
Having  carefully  searched  the  literature  Rich- 
ardson was  able  to  find  one  case  ("Case  of 
Chas.  F.  Freeman,  of  Pocasset.  Mass.,"  by  C. 
F.  Folsom,  M.  D.,  Amer.  Jour,  of  Insanity,  vol. 
40,  p.  353.)  which  was  identical  in  many  re- 
spects with  his  own,  and  a  second  one,  reported 
by  Dr.  Henry  M.  Hurd,  (Annual  Report  of  the 
Eastern  Michigan  Hospital  for  Insane  for  the 


382  Psychopathology  of  Hysteria 

year  1884)  which  showed  points  of  resemblance. 

Though  the  prognosis  may  usually  be  con- 
sidered to  be  good  it  must  be  remembered  that 
hysteric  insanity  at  times  is  only  a  forerunner 
of  real  insanity,  and  that  it  is  not  uncommon 
to  discover  what  appear  to  be  manifestations 
of  hysteria  in  patients  whose  actual  insanity  is 
in  a  stage  of  evolution. 

Theories.  Before  taking  up  some  of  the 
views  of  Janet  and  of  Freud  let  us  examine  in 
abstract  some  interesting  biologic  conceptions 
held  by  Jelliffe.  (N.  Y.  Med.  Jour.,  May  16, 
1908.)  For  Jelliffe  hysteria  in  an  adult  con- 
sists in  a  collection  of  primitive  modes  of  re- 
action. Ontogenetically,  hysteric  individuals 
are  matured  children;  phylogenetically,  they 
are  instructed  savages.  The  mental  character- 
istics of  hysteria  comprise  instability — particu- 
larly emotional  instability — suggestibility,  nega- 
tivism, and  egocentricity.  Desire  to  be  the 
centre  of  attention  causes  the  savage  to  strut 
about  in  feathers  and  paint,  while  in  hysteria 
the  same  egocentricity,  here  a  manifestation  of 
atavism,  is  the  motive  for  romantic  accusations, 
self  inflicted  mutilations,  and  for  theatrical 
attempts  at  suicide.  Practically  all  the  physi- 
cal signs  result  from  abnormal  suggestibility. 
Lack  of  logical  judgment  is  the  chief  character- 
istic of  the  normal  mentality  of  the  child,  and 
as  hysteria  represents  reversion  towards  the 
infantile  type  this  characteristic  leads  to  a  sys- 


Hysteric  Temperament  383 

tern  of  autosuggestion  which  may  terminate  in 
profound  disturbances  of  personality.  ''The 
importance  of  moral  causes  in  the  development 
of  hysterical  states  cannot  be  overestimated. 
From  this  point  of  viev\r  we  may  consider 
hysteria  as  a  series  of  abnormal  reactions  of 
the  individual  to  the  exigencies  of  life.  These 
abnormal  modes  of  reaction  are  often  the  conse- 
quence of  the  fetters,  or  the  obstacles  which  the 
moral  and  social  order  impose  upon  the  expres- 
sion of  the  natural  tendencies  of  man  and  show 
themselves  the  more  strongly  the  closer  the 
man  approaches  the  child  viewpoint.'^  The 
association  of  hysteria  with  organic  disease 
strictly  accords  vdth  the  ''hypothesis  that  the 
superior  individual  is  one  who  by  intelligence 
and  by  training  has  developed  past  his  hyster- 
ical infancy,  or  youth,  but  let  intercurrent 
disease  reduce  his  resistance,  or  sink  the  level 
of  his  nervous  tension,  as  Janet  would  express 
it,  and  a  natural  reversion  to  primitive  traits 
is  to  be  expected."  Beside  symptomatic  hys- 
teria and  the  evolutive  type  representing  only 
an  accident  in  the  mental  evolution  of  the  in- 
dividual, or  of  the  species,  there  is  a  third  group 
of  cases  composed  of  degenerative  hysterias — 
of  hysteria  developed  upon  a  distinct  neuro- 
pathic heredity. 

Man  strives  to  place  all  phenomena  upon 
a  physical  basis,  and  among  these  has  been 
included  hysteria.       Applying  to  hysteria  the 


384  Psychopathology  of  Hysteria 

hypothesis  of  Rabl-Riickhard  it  has  been  pro- 
posed to  explain  the  condition  by  assuming  that 
the  underlying  pathologic  mechanism  is  one  of 
dendritic  retraction.  Beside  the  fact  that  this 
theory  is  but  feebly  supported  by  facts,  and 
that  it  has  been  rejected  in  many  authoritative 
quarters,  its  application  to  hysteria  does  not 
explain  in  a  satisfactory  manner  the  pathology 
of  the  disease,  no  matter  how  attractive  at  first 
it  may  seem.  Where  does  the  retraction  take 
place  in  case  of  psychic  anaesthesia?  What 
cells  are  isolated?  Sensory  impressions  from 
the  anaesthetic  region  not  only  are  perceived, 
as  shown  elsewhere,  but  apperception  occurs, 
and  an  intelligently  directed  motor  response 
may  take  place.  Therefore,  the  cortical  cells 
which  receive  the  impulses  are  not  isolated  and 
retraction  of  dendrites  would  have  to  involve 
over  half  of  the  cells  of  the  brain,  thus  pro- 
ducing a  true  double  personality.  It  would  be 
difficult  to  explain  how  retraction  of  dendrites 
could  produce  a  case  of  double  consciousness  m 
which  the  morbid  personality  possessed  the 
memories  of  both  states  while  the  first  one  is 
limited  to  its  own.  Finally,  retraction  of  den- 
drites not  only  must  be  capable  of  being  in- 
duced by  suggestion,  more  or  less  independent 
convictions,  etc.,  but  of  being  dispelled  by  the 
same  factors. 

The  most  important  of  the  early  advances  in 
the  study  of  hysteria  was  the  recognition  by 


Hysteric  Temperament  385 

Jules  Janet,  in  1888,  of  the  disintegration  of 
personality  which  occurs  in  the  disease.  About 
the  same  time  Pierre  Janet  began  to  develop  the 
psychopathology  of  hysteria  upon  a  basis  of  sub- 
conscious fixed  ideas,  or  of  dissociated  memory 
complexes.  According  to  his  conception  of  the 
disease  the  most  characteristic  manifestation  is 
somnambulism;  a  condition  dependent  upon 
cleavage  from  the  usual  state  of  consciousness  of 
a  system,  or  of  systems,  of  memories.  "When 
somnambulistic  crises  result  from  the  activity  of 
a  single  dissociated  system  of  ideas  the  condition 
is  termed  monoideic  somnambulism.  Polyideic 
somnambulism  and  fugues  result  from  dissocia- 
tion of  a  number  of  systems,  and  multiple  per- 
sonality, the  ultimate  of  dissociation,  represents 
massive  disintegration  of  personality.  The  many 
other  attacks  of  hysteria  are  merely  abortive  or 
imperfect  types  of  somnambulism. 

Janet  believes  that  the  deficiencies  of  con- 
scious perception  are  capable  of  being  explained 
by  assuming  that  as  a  result  of  retraction  of 
the  field  of  consciousness  there  occurs  a  kind  of 
absent-mindedness;  being  unable  to  attend  to 
many  kinds  of  sensory  impressions  the  patient 
gets  into  the  habit  of  not  consciously  attend- 
ing to  the  ones  which  are  least  important  to  her. 
When  the  habit  becomes  fixed  anaesthesia,  amau- 
rosis, etc.,  result.  He  defines  the  disease  as  "a 
form  of  mental  depression  characterized  by  the 
retraction  of  the  field  of  personal  consciousness 


386  Psychopathology  of  Hysteria 

and  a  tendency  to  the  dissociation  and  emanci- 
pation of  the  systems  of  ideas  and  functions 
that  constitute  personality." 

According  to  Babinski  the  stigmata  are  always 
the  effect  of  suggestion;  usually  of  medical 
origin.  He  defines  hysteria  as  a  psychic  state 
which  renders  the  patient  susceptible  to  sugges- 
tion. It  is  manifested  principally  by  primary 
disorders  and  accessorily  by  secondary  disturb- 
ances. What  characterizes  the  first  is  the  possi- 
bility of  reproducing  them  by  suggestion  with 
rigorous  exactitude  in  certain  subjects  and  of 
making  them  disappear  under  the  exclusive  in- 
fluence of  persuasion.  Wliat  characterizes  the 
secondary  disturbances  is  that  they  are  strictly 
subordinated  to  the  primary  disorders. 

In  1893  a  new  epoch  in  the  study  of  hysteria 
was  initiated  by  the  contribution  of  Breuer  and 
Freud,  and  at  present  Freud's  highly  elaborated 
conception  of  submerged  complexes  and  the  re- 
sults of  their  activity  is  the  one  which  is  rapidly 
finding  acceptance  in  neurologic  circles.  The 
theories  both  of  Freud  and  of  Janet  have  been 
drawn  upon  extensively  in  the  composition  of 
the  body  of  this  work;  in  this  section  it  is  in- 
tended merely  to  recapitulate  some  of  the  more 
important  and  less  complicated  of  Freud's  inves- 
tigations. 

Before  taking  up  some  of  his  original  theories 
let  us  first  quote  from  the  Peterson  and  Brill 
translation  two  sentences  which  indicate  Freud's 


Hysteric    Temperament  387 

agreement  with  the  results  of  researches  com- 
menced by  the  French  school:  "...  the 
splitting  of  consciousness,  so  striking  in  the 
familiar  classical  cases  of  double  consciousness 
exists  rudimentarily  in  every  hysteria,  and  that 
the  tendency  to  this  dissociation,  and  with  it 
the  tendency  towards  the  appearance  of  abnor- 
mal states  of  consciousness  which  we  compre- 
hend as  'hypnoid  states,'  is  the  chief  phenom- 
enon of  this  neurosis. '^  "A  persistent  hyster- 
ical symptom  therefore  corresponds  to  a  projec- 
tion of  this  second  state  into  a  bodily  inner- 
vation otherwise  controlled  by  the  normal 
consciousness.  A  hysterical  attack  gives  evi- 
dence of  a  higher  organization  of  this  second 
state,  and  if  of  recent  origin  it  signifies  a 
moment  in  which  this  hypnoid  consciousness 
gained  control  of  the  whole  existence,  and 
hence  we  have  an  acute  hysteria,  but  if  it  is 
a  recurrent  attack  containing  a  memory  we 
simply  have  a  repetition  of  the  same." 

Normally  the  effects  of  an  emotion  which  has 
not  been  adequately  externalized  may  be 
worked  off  by  means  of  subsequent  verbal 
expression — giving  vent  to  one's  feelings.  Or 
these  deleterious  effects  may  be  neutralized  by 
association  with  antagonistic  ideas.  For  ex- 
ample, the  painful  memories  of  an  accident 
are  rendered  inocuous  by  association  of  ideas 
with  its  fortunate  termination.  When,  as  a 
reaction  of  defense,  an  individual  strives  to  for- 


388  Psychopathology  of  Hysteria 

get  the  painful  memories  of  some  experience 
and  thus  fails  adequately  to  express  the  emo- 
tional feeling,  the  memory  complex  of  the 
occurrence  may  become  submerged,  or  disso- 
ciated. The  motives  for  suppression  of  various 
ideas  and  mental  states  may  be  consequent 
upon  moral  training,  social  environment,  or 
upon  the  painful  nature  of  the  ideas  them- 
selves. All  ideas  which  tend  to  bring  the  disso- 
ciated complex  into  the  stream  of  conscious- 
ness themselves  are  dissociated  as  secondary 
reactions  of  defense,  with  the  result  that  the 
original  complex  becomes  surrounded  by  a 
continually  increasing  number  of  associated 
constellations  until  the  whole,  by  a  process  of 
conversion,  may  react  upon  the  patient  by  pro- 
ducing any  of  the  various  manifestations  of 
hysteria.  These  manifestations  are  merely 
symbolic  representations  of  what  has  been 
repressed,  or  they  may  be  fixed  or  recurring 
symptoms  derived  from  phenomena  which  were 
accidentally  associated  with  the  emotional 
experience  which  served  as  the  exciting  cause. 
When  tracing  back,  by  means  of  psycho- 
analysis, the  different  levels  of  psychic 
traumata  from  which  symptoms  were  derived, 
Freud  found  that  invariably  they  led  back  to 
sexual  experiences  of  early  childhood.  Inas- 
much as  perpetuation  of  the  species  is  depend- 
ent upon  the  sexual  instinct,  this  force  is  most 
obtrusive  and  far  reaching ;  its  influence  being 


Hysteric    Temperament  389 

perceptible  in  nmch  of  our  activity,  even 
though  commonly  this  is  not  fully  appreciated. 
Having  such  a  vast  number  of  ramifications, 
it  is  but  natural  that  this  instinct  should  exert 
a  tremendous  influence  in  the  genesis  of  psy- 
choneuroses. 

Sexual  modesty  having  been  acquired  by 
precept,  and  by  education,  normal  sexual  long- 
ings are  consciously  repressed  as  immoral  and 
reprehensible,  with  the  consequence  that  ulti- 
mately the  dissociated  ideas  may  become  con- 
verted into  physical  symptoms,  or  into  obses- 
sions, just  as  the  force  of  the  instinct  may  be 
converted  into  increased  professional  activity 
and  thus  expressed.  Morbid  anxiety  and  other 
obsessions  are  deviations  due  to  repression  of 
sexual  desire  from  its  natural  mode  of  expres- 
sion: they  are  transformed  reproaches  for 
pleasurably  accomplished  sexual  activity  of 
childhood.  Hysteria  is  the  outcome  of  a  con- 
flict between  libido  and  sexual  repression; 
the  symptoms  being  a  compromise  between 
two  antagonistic  psychic  systems.  Apparent 
lack  of  sexual  impulses  is  due  to  successful 
repression  of  the  sexual  instinct,  and  is  accom- 
panied by  commensurate  substitution  of  some 
other  kind  of  expression.  The  psychic 
traumata  from  which  symptoms  of  hysteria 
are  derived,  are  experiences  concerning  the 
sexual  life  of  the  child,  even  though  the  excit- 
ing cause  be  some  emotion  of  a  non-sexual 
nature. 


390  Psychopathology  of  Hysteria 

When  consciousness  is  at  its  normal  mini- 
mum— during  sleep — inhibition  is  so  reduced 
that  suppressed  complexes  assert  themselves. 
Dreams,  therefore,  are  elaborated  and  fanci- 
ful expressions  of  desires  which  have  been 
consciously  repressed  as  incompatible  with  the 
ego.  Being  such,  investigation  and  intelligent 
interpretation  of  the  content  of  dreams  leads 
to  valuable  information  concerning  submerged 
complexes. 

In  support  of  his  views  regarding  sub- 
conscious pathogenic  memory  complexes,  Freud 
has  made  careful  studies  of  the  normal  activity 
of  complexes  which  do  not  rise  to  the  level  of 
consciousness,  and  he  has  shown  that  much  of 
our  psychic  activity  is  dependent  upon  motives 
of  which  we  are  ignorant.  We  act  from 
motives  of  which  consciously  we  are  unaware, 
and  in  our  ignorance  we  ascribe  our  actions  to 
motives  which,  in  reality,  are  fictitious.  When 
we  are  unable  to  recall  a  familiar  name,  and  in 
its  place  others  arise,  only  to  be  rejected,  the 
whole  is  not  a  matter  of  chance.  Analysis  of 
such  incidents  shows  that  the  name  cannot  be 
recalled  because  of  its  association  with  some 
disagreeable  ideas  which  have  been  repressed. 
For  example,  Freud  was  unable  to  recognize  a 
name  which  he  came  across  in  one  of  his 
account  books.  The  subconscious  motive — dis- 
covered later — consisted  in  the  fact  that  he 
had  overlooked  a  pelvic  sarcoma  while  treat- 
ing the  patient  for  symptoms  of  hysteria. 


Hysteric    Temperament  391 

An  individual  turns  a  deaf  ear  to  any  argu- 
ments concerning  his  religious  convictions  be- 
cause, as  he  thinks,  it  would  be  sacrilegious  to 
enter  into  any  such  discussions.  He  is  not  aware 
of  any  other  and  more  fundamental  reason  for 
his  disinclination  to  argue  the  point,  yet  the  real 
incentive  is  his  own  suppressed  tendency  to  ques- 
tion the  rationality  of  his  superficial  beliefs. 
That  a  person  can  perform  an  act  as  a  conse- 
quence of  the  activity  of  a  submerged  complex 
and  yet  believe  that  he  is  acting  in  accordance 
with  some  other  and  entirely  different  motive  is 
not  as  improbable  as  at  first  it  may  seem.  The 
controlling  influence  of  subconscious  complexes 
is  best  illustrated  by  the  manner  in  which  an 
indi^ddual  accounts  for  an  act  which  was  really 
imposed  upon  him  by  post-hypnotic  suggestion. 
The  following  incident  related  by  Jastrow  is  a 
good  example  of  unconscious  falsification  of 
motives : 

''In  a  garden,  on  a  hot  summer  day,  when  all 
-energies  are  relaxed,  a  mother  requests  her 
daughter  to  get  a  certain  book  from  the  study- 
table.  The  request  seemingly  goes  unheeded, 
for  the  daughter  continues  to  loll  in  the  ham- 
mock. Yet  presently  she  goes  to  the  house  and 
returns  with  the  book  and  the  explanation, 
^Mother,  I  happened  to  see  your  book,  and 
thought  you  might  want  it.'  Her  surprise  at 
the  laughter  that  greeted  her  remark  sufficiently 
attested  her  unawareness  of  the  source  of  the 


392  Psychopathology  of  Hysteria 

impulse    upon    which    she    had    acted."     (The 
Subconscious,  1906,  p.  134.) 


For  further  information  concerning  Freud's  work 
the  following  English  translations,  reviews,  and 
other  papers  upon  which  I  have  been  largely  de- 
pendent may  be  recommended: 

Freud:  Selected  Papers  on  Hysteria,  trans,  by  A. 
A.  Brill,  1909. 

Freud:  Three  Contributions  to  the  Sexual  The- 
ory, trans,  by  A.  A.  Brill,  1910. 

Brill:  Freud's  Conception  of  the  Psychoneuroses, 
Med.  Record,  Dec.  25,  1909. 

Brill:  The  Anxiety  Neuroses,  Jour,  of  Abnormal 
Psychology,  vol.   5,  p.   57. 

Putnam:  Recent  Experiences  in  the  Study  and 
Treatment  of  Hysteria  at  the  Massachusetts  Gen- 
eral Hospital;  with  Remarks  on  Freud's  Method 
of  Treatment  by  "Psycho-Analysis."  Jour,  of 
Abnormal  Psychology,  vol.  1,  p.  26. 

Putnam:  Personal  Experience  with  Freud's  Psy- 
choanalytic Method,  Jour,  of  Nervous  and  Men- 
tal Disease,  1910,  p.  657. 

Putnam:  Personal  Impressions  of  Sigmund  Freud 
and  His  Work,  with  Special  Reference  to  His 
Recent  Lectures  at  Clark  University,  Jour,  of 
Abnormal  Psychology,  vol.  4,  pp.  293  and  372. 

Coriat:  A  Contribution  to  the  Psychopathology  of 
Hysteria,  Jour,  of  Abnormal  Psychology,  vol.  6, 
p.  33. 

Jones:  Psycho-Analysis  in  Psychotherapy,  Jour,  of 
Abnormal  Psychology,  vol.  4,  p.  140. 

Jones:  Rationalization  in  Every-day  Life,  Jour,  of 
Abnormal  Psychology,  vol.  3,  p.   161. 

Jones:  The  Psycho-Analytic  Method  of  Treat- 
ment, Jour,  of  Nerv.  and  Ment.  Dis.,  1910,  p.  285. 

Hart:  Freud's  Conception  of  Hysteria,  Brain,  p. 
339,  1911. 

In  connection  with  Freud's  theories  the  follow- 
ing papers  also  are  of  great  interest: 

Jung:  Psychology  of  Dementia  Praecox,  Peterson 
and  Brill  trans.,  1909. 


Hysteric   Temperament  393 

Brill:  Psj'chological  Factors  in  Dementia  Praecox, 
Jour,  of  Abnormal  Psychology,  vol.  3,  p.  219. 

Jones:  Remarks  on  a  Case  of  Complete  Auto- 
Psychic  Amnesia,  Jour,  of  Abnormal  Psychology, 
vol.  4,  p.  218. 

Onuf:  Dreams  and  Their  Interpretation  as  Diag- 
nostic and  Therapeutic  Aids  in  Psychopathology, 
Jour,  of  Abnormal  Psychology,  vol.  4,  p.  339. 


CHAPTER  XI 

Diagnosis^  Prognosis  and  Treatment 

THE  diagnosis  of  hysteria — a  disease 
which  is  capable  of  mimicking  closely 
practically  all  other  diseases,  and  which 
occurs  so  frequently  in  association  with 
organic  maladies — often  must  be  attended  with 
great  difficulties.  Not  only  are  the  symptoms 
of  hysteria  innumerable,  but  constantly  one  en- 
counters unique  cases  presenting  symptoms 
which  never  before  have  been  described,  and 
w^hich  can  be  recognized  as  manifestations  of 
this  disease  only  by  analysis  of  the  psychic  fac- 
tors which  enter  into  their  production.  Provid- 
ing that  an  adequate  examination  has  been  made, 
the  diagnosis  of  typical  cases  is  easy;  but  such 
cases  are  uncommon. 

In  males,  in  children,  and  in  the  aged,  the 
diagnosis  may  be  encompassed  with  greater 
difficulties  than  usual.  In  children,  and  in 
males,  the  disease  is  prone  to  be  monosymp- 
tomatic,  and  frequently  these  patients  do  not 
present  much  evidence  of  what  is  designated 
the  hysteric  temperament.  In  the  aged  symp- 
toms of  hysteria  often  mask  those  of  organic 
disease,  and  besides,  the  fact  that  the  patient 
is  beyond  middle  life  is  apt  to  lessen  the  chances 
of  ascribing  to  hysteria  symptoms  which  are 
really  due  to  this  disease. 

394 


Diagnosis,  Prognosis  mid  Treatment     395 

Often  the  diagnosis  is  made  merely  on  the 
evidence  afforded  by  emotional  instability,  and 
general  ''crankiness";  and  this  may  be  ac- 
complished without  first  having  eliminated  the 
possibility  of  co-existence  of  some  other,  and 
perhaps  more  serious,  disease  whose  treatment 
is  of  far  greater  importance.  Quite  commonly 
the  general  practitioner  makes  the  mistake  of 
considering  as  hysteric  the  more  or  less  inten- 
tional emotional  outbreaks  — ' '  hysterics ' ' —  of 
pampered  children  and  wives ;  disturbances  cal- 
culated to  break  down  the  resistance  of  those 
who  oppose  their  vagaries.  And,  on  the  other 
hand,  as  a  result  of  such  a  conception  of  the 
disease  the  manifestations  of  frank  hysteria  too 
often  are  regarded  as  those  of  organic  disease. 
Ordinarily  there  is  far  greater  chance  of  mis- 
taking for  organic  disease  the  many  kinds  of 
paralysis,  contractures,  convulsions,  etc.,  than 
of  making  errors  in  the  recognition  of  mani- 
festations of  actual  organic  disease.  Besides 
being  essential,  thorough  examination  not  only 
will  decrease  the  unwarranted  frequency  with 
which  the  diagnosis  hysteria  is  abused,  but  it  will 
enable  one  rigidly  to  exclude,  and  the  necessity 
for  this  cannot  be  too  greatly  emphasized,  or  to 
recognize  the  coexistence  of,  organic  disease. 

As  suggestion  is  at  the  foundation  of  most 
hysteric  ''accidents"  the  physician  should  con- 
stantly be  on  guard  in  order  not  to  develop  new 
symptoms  by  reason  of  a  faulty  technique  of 


396  Psychopathology  of  Hysteria 

examination,  and,  in  the  treatment  of  patients, 
not  to  prolong  by  an  injudicious  amount  of  at- 
tention the  duration  of  symptoms  which  already 
are  present.  Naturally  the  existence  of  psy- 
choneuroses  does  not  prevent  the  occurrence  of 
other  diseases,  so  that  the  diagnosis  hysteria  is 
never  complete  unless  these  either  have  been 
recognized  or  excluded.  Infrequently  it  may 
be  impossible  to  decide  definitely  whether  a 
case  is  one  of  hysteria  or  of  organic  disease,  and, 
in  these  cases,  it  may  be  necessary  to  keep  a  pa- 
tient under  prolonged  observation  before  a  posi- 
tive diagnosis  can  be  made  with  any  degree  of 
accuracy. 

Analysis  of  dispensary  and  private  records 
shows  that  hysteria  is  about  one-third  as 
frequent  as  psychasthenia,  and  that  the  sexual 
incidence  in  hysteria  is  about  M :  F : :  1 :  3, 
while  in  psychasthenia  the  ratio  is  almost 
equal;  males  being  slightly  in  excess.  It  should 
be  added,  however,  that  many  cases  which  were 
classified  as  psychasthenia  might  be  designated 
by  others  as  cases  of  neurasthenia,  hysteria,  or 
hypochondriasis. 

In  attempting  to  separate  into  different  func- 
tional diseases  various  abnormal  manifestations 
of  psychic  origin,  it  should  be  remembered  that 
we  are  merely  classifying  in  an  arbitrary  man- 
ner, and  purely  for  clinical  purposes,  different 
types  of  abnormal  reactions  which  necessarily 
must  vary  to  the  same  degree  that  even  nor- 


Diagnosis,  Prognosis  and  Treatment    397 

mal  individuals  vary.  Being  characterized  by 
perverted  reactions  of  the  individual  to  his 
environment,  any  attempt  symptomatically  to 
classify  the  psychoneuroses  must  be  arbitrary 
and  unsatisfactory. 

What  are  called  hysteria,  psychasthenia, 
neurasthenia,  hypochondriasis,  and  multiple 
personality,  are  only  clinical  syndromes,  and 
as  such  their  differentiation  is  often  difficult, 
if  not  impossible.  Hence,  cases  which  might 
be  considered  neurasthenia  by  one  physician 
would  be  designated  hysteria  by  another,  and 
psychasthenia  or  hypochondriasis  by  a  third. 

The  impossibility  of  arriving  at  a  satisfac- 
tory symptomatic  classification  of  psychoneuro- 
sis  corresponds  with  the  abandoned  attempts 
symptomatically  to  classify  insanity.  Such  at- 
tempts must  fail  for  the  same  reason  that  it 
would  be  impossible  to  classify  mankind 
according  to  the  manner  in  which  individuals 
react  to  various  environmental  stimuli.  "It  is 
the  men  of  science  who  cut  separate  pieces  out 
of  a  whole  that  nature  has  made  continuous." 
(Janet). 

The  differential  diagnosis  of  the  psycho- 
neuroses  still  further  is  complicated  by  the  fre- 
quent occurrence  of  cases  into  whose  composi- 
tion enter  symptoms  of  hysteria  and  of  psychas- 
thenia, or  of  hysteria  and  neurasthenia.  As 
careful  study  resolves  most,  if  not  all,  cases  of 
neurasthenia  into  hysteria  and  psychasthenia  the 


398  Psychopathology  of  Hysteria 

present  tendency  is  to  abolish  neurasthenia  as  a 
clinical  entity.  In  fact,  Prince  considers  the 
neurasthenic  state  to  be  one  of  the  stigmata  of 
hysteria.  Many  of  the  cases  which  formerly 
were  classified  under  the  name  hypochondriasis 
— of  which  we  hear  but  little  in  these  days — 
are  now  regarded  as  types  of  psychasthenia.  In 
view  of  the  unsatisfactory  nature  of  the  usual 
symptomatic  classifications,  still  further  tend- 
ency towards  unification  has  been  evidenced  by 
the  proposal  that  we  should  abandon  attempts 
to  classify  the  functional  neuroses,  and  that  all 
of  these  cases  be  grouped  under  the  term  psy- 
choneuroses.  Such  a  careless  mode  of  solving, 
or  rather  of  escaping  from,  the  problem  would 
be  just  as  much  an  instance  of  retrogression  as 
w^ould  be  relinquishment  of  attempts  to  classify 
alienation  and  merely  to  be  satisfied  with  the 
term  insanity. 

The  only  value  possessed  by  the  diagnoses 
hysteria,  psychasthenia,  neurasthenia,  and  hypo- 
chondriasis, is  the  fact  that  these  terms  convey 
some  idea  of  the  character  of  the  manifestations 
presented  by  a  patient.  Having  the  same  end 
in  view,  however,  one  might  proceed  indefinitely 
to  divide  these  conditions  into  gastric  neuroses, 
cardiac  neuroses,  sexual  neuroses,  innumerable 
varieties  of  phobias,  etc. 

Enough  has  been  said  in  describing  the  indi- 
vidual symptoms  of  hysteria  to  render  unneces- 
sary their  detailed  differentiation  from  those  of. 
organic  disease.     As  combinations  of  symptoms 


Diagnosis,  Prognosis  and  Treatment    399 

of  hysteria  may  mimic  closely  other  diseases  it 
is  advisable,  however,  briefly  to  consider  several 
of  these.  Excluding  epilepsy,  probably  the  most 
difficult  diagnostic  problem  consists  in  the  dif- 
ferentiation of  some  cases  of  hysteria  from  mul- 
tiple sclerosis.  In  both  diseases  symptoms  often 
appear  suddenly  in  an  emotional  young  woman, 
and,  after  having  persisted  a  varying  length  of 
time,  disappear  just  as  abruptly.  In  each  dis- 
ease there  is  no  fixed  order  of  appearance  of 
symptoms;  neither  is  there  much  limitation  to 
symptomatic  possibilities.  In  some  cases  of  mul- 
tiple sclerosis  which  appear  to  be  uncomplicated 
by  hysteria  the  patient  may  display  emotional 
outbursts  and  evidences  of  what  constitutes  the 
classic  hysteric  temperament.  These  manifes- 
tations are  supposed  to  be  due  to  plaques  of 
sclerosis  in  the  optic  thalamus.  As  multiple 
sclerosis  is  so  generally  complicated  by  hysteria 
the  ability  to  make  a  positive  diagnosis  of  hys- 
teria never  excludes  the  possibility  of  co-exist- 
ence of  multiple  sclerosis,  or,  in  fact,  of  any  other 
organic  disease.  In  doubtful  cases  typical 
organic  kind  of  exaggeration  of  the  tendon 
reflexes,  presence  of  true  ankle  clonus,  of  the 
Babinski  sign,  and  of  atrophic  changes  in  the 
optic  discs,  always  signify  the  presence  of  mul- 
tiple sclerosis,  or  of  some  other  organic  ner- 
vous disease. 

Acute  and  chronic  abdominal  disease  may  be 
closely  mimicked  by  hysteria,  and  even  though 


400  PsycJwpathology  of  Hysteria 

this  functional  neurosis  is  known  to  be  present 
the  difficulty  of  excluding  appendicitis,  gastric 
ulcer,  etc.,  may  be  great.  The  fact  that  the 
patient  is  known  to  be  a  hysteric  is  very  apt  to 
lead  to  greater  diagnostic  uncertainty  by  reason 
of  fear  of  being  biased  and  thus  ascribing  to 
the  hysteric  element  symptoms  of  some  serious 
organic  disease.  A  valuable  differentiating 
sign  consists  in  the  fact  that  hysteric  patients 
usually  breathe  more  deeply  when  pressure  is 
exerted  over  a  painful  abdominal  region,  while 
in  organic  abdominal  disease  the  actual  pain 
resulting  from  localized  pressure  prevents  deep 
respiration  and  the  patient  either  momentarily 
ceases  to  breathe,  or  the  respirations  become 
quite  shallow. 

When  it  is  impossible  to  eliminate  positively 
organic  disease  it  is  essential  to  treat  the  patient 
as  though  the  condition  were  organic,  and  if 
the  necessity  for  an  operation  appears  to  be 
absolute,  then  it  is  preferable  to  operate  un- 
necessarily on  several  cases  of  hysteria  rather 
than  to  allow  one  case  of  hysteria  to  die  be- 
cause actual  appendicitis,  for  instance,  arose  as 
a  neglected  complication. 

When  hysteric  patients  simulate  disease  in 
order  to  command  attention  and  sympathy 
curious  diagnostic  problems  may  arise.  Among 
these  may  be  mentioned  those  patients  with 
hysteric  vomiting  who  simulate  gastric  ulcer  by 
means  of  vomiting  blood  which  they  have  ob- 


Diagnosis f  Prognosis  and  Treatment    401 

tained  by  causing  epistaxis  and  then  swallow- 
ing the  blood. 

Course  and  Prognosis.  In  my  opinion  hys- 
teria is  rarely  cured.  The  manifestations  of 
the  disease  can  be  removed  easily  in  most  cases, 
and  the  morbid  temperament  of  the  patient 
somewhat  modified,  but  all  the  accidents  con- 
tinue to  exist  as  potentialities  which  may  be- 
come actual  at  any  time,  providing  that  suf- 
ficient provocation  occurs.  The  ''cure"  of  these 
cases  resembles  the  "cure"  of  pulmonary  tu- 
berculosis in  that  symptoms  of  either  disease 
may  be  caused  to  subside,  and  the  underlying 
predisposition  diminished,  but  we  well  know 
that  both  of  these  conditions  have  become  mere- 
ly latent. 

Provided  that  the  patient  has  not  instituted 
legal  proceedings,  monosymptomatic  hysteria 
resulting  from  injury  is  much  more  amenable 
to  treatment  than  other  forms  of  the  disease  in 
adults.  If  such  patients  come  under  intelligent 
treatment  soon  after  the  onset,  the  symptoms 
almost  invariably  can  be  removed  without  dif- 
ficulty. If  the  symptoms  have  existed  for  a  long 
time,  then  they  may  have  become  so  fixed  as  to 
be  more  or  less  permanent  in  spite  of  the  most 
prolonged  and  careful  treatment.  Ordinarily, 
the  longer  a  symptom  has  existed  the  more 
resistant  it  is  to  treatment. 

"With  the  pure  forms  of  hysteria  occurring  in 
children,  the  results  of  treatment  are  eminently 


402  Psychopathology  of  Hysteria 

satisfactory,  and  the  ultimate  prognosis  is  much 
better  than  with  adults.  The  reason  for  this  is 
evident  when  one  stops  to  consider  that  the 
minds  of  children  are  in  the  stage  of  evolution, 
and,  being  plastic,  are  easily  influenced.  The 
harmful  results,  too,  of  faulty  education  and 
environment  can  be  corrected  more  readily 
before  emotional  instability  has  become  habitual. 

Without  treatment  symptoms  may  vanish 
during  an  emotional  shock,  or  in  the  absence  of 
any  apparent  cause.  Sometimes,  after  having 
resisted  all  forms  of  treatment,  they  disappear 
spontaneously  as  the  result  of  most  curious  and 
trivial  incidents.  Wilson  mentions  just  such 
a  case.  (Brain,  1910,  p.  313).  A  young 
woman  gradually  developed  mutism  that  was 
completely  resistant  to  treatment.  Long  after 
leaving  the  hospital  she  discovered  that  she  had 
been  right  in  an  argument  she  had  had  with 
her  aunt  before  the  mutism  had  developed.  In 
her  elation  she  cried  out:  "I'm  right,"  and 
then:  "Oh,  I've  spoken,  auntie!"  Wilson  re- 
marks that  from  that  moment  her  recovery  was 
complete  and  lasting. 

Some  patients  avail  themselves  of  their  dis- 
ease in  order  to  obtain  their  own  ends,  and  un- 
der such  circumstances  the  physician  works  at 
a  disadvantage.  The  cases  which  are  most  re- 
sistant to  treatment  are  those  in  which  the 
disease  appears  after  middle  life,  and  those 
subjects  of  traumatic  hysteria  whose  recovery 


Diagnosis,  Prognosis  and  Treatment     403 

to  a  great  degree  is  prevented  by  protracted 
legal  proceedings  whose  " favorable  "  outcome  is 
dependent  upon  the  severity  and  hopelessness 
of  their  condition.  Even  though  the  latter  sin- 
cerely desire  to  be  cured  of  their  manifestations 
the  fact  alone  that  a  lawsuit  is  in  progress,  to 
say  nothing  of  the  suggestive  effects  of  the 
pro  gnostic  ally  unfavorable  testimony  to  which 
they  are  exposed,  is  most  conducive  to  the 
indefinite  continuance  of  the  disease.  If  par- 
alysis can  be  induced  by  suggestion  alone  cer- 
tainly it  can  be  caused  to  become  more  or  less 
permanent  when  the  patient  hears  an  expert 
testify  that  such  may  be  the  case. 

The  prognosis  is  bad,  also,  in  those  who  de- 
velop hysteria  upon  a  foundation  of  decided 
neuropathic  heredity,  and  whose  environment 
is  unfavorable,  as  usually  it  is  in  these  cases. 
Even  though  their  symptoms  may  be  readily 
removed,  recurrence  of  old,  or  the  development 
of  new,  manifestations  sooner  or  later  is  al- 
most inevitable. 

In  arriving  at  a  prognosis  the  apparent 
severity  of  a  symptom  is  not  a  criterion.  Often 
the  most  severe  symptoms  are  controlled  much 
more  readily  than  those  which  seem  almost 
negligible.  The  removal  of  a  convulsive 
tendency,  for  instance,  is  much  less  difficult 
than  the  cure  of  a  long  standing  functional 
headache.  If  patients  do  not  receive  any  treat- 
ment usually  the  manifestations  gradually  or 


404  Psychopathology  of  Hysteria 

suddenly  disappear  to  be  replaced  by  others,  or 
the  patient  may  remain  comparatively  free 
from  obvious  symptoms  for  an  indefinite  time. 
Often,  too,  a  symptom  which  has  been  produced 
by  one  emotional  shock  will  disappear  suddenly 
after  a  second  one.  It  should  be  remembered 
that  not  infrequently  major  symptoms  have 
persisted  for  many  years  in  spite  of  treatment. 
More  than  one  hysteric  afflicted  with  a  psychic 
paraplegia,  for  instance,  has  been  confined  to 
bed  many  years,  or,  in  fact,  until  death  oc- 
curred. As  far  as  death  is  concerned  the  prog- 
nosis of  hysteria  is  excellent.  Almost  the  only 
symptom  which  is  capable  of  causing  death  is 
hysteric  anorexia ;  the  patient  dying  from  star- 
vation. Such  fatalities,  formerly  so  frequent, 
would  not  be  permitted  to  occur  at  present. 

Prophylaxis.  The  prophylaxis  of  hysteria 
is  little  more  than  the  application  of  cor- 
rect methods  of  education — using  this  term  in 
its  most  comprehensive  sense.  By  a  process  of 
hardening,,  predisposed  children  should  be  edu- 
cated psychically  to  react  in  a  normal  man- 
ner not  only  to  the  usual  stresses  of  life,  but 
to  the  more  severe  psychic  insults  to  which  all 
are  exposed.  Most  essential  is  the  develop- 
ment of  proper  realization  of  true  relations  with 
the  outside  world:  to  cause  the  individual  to 
appreciate  that  she  is  only  a  unit  in  a  vast 
system. 

As  the  parents  of  nervous  children  are  often 


Diagnosis,  Prognosis  and  Treatment     405 

nervous  tliemselves  the  influence  of  psychic 
contagion  should  be  avoided,  if  possible,  by 
changing  the  child's  environment.  If  old 
enough  she  may  be  sent  to  a  boarding  school, 
and  thus  the  beneficial  effects  of  discipline  and 
of  constant  association  with  many  normal  chil- 
dren are  gained,  and,  furthermore,  she  passes 
through  experiences  which  tend  to  promote  self- 
reliance. 

,Sedentary  habits  should  be  discouraged,  and 
a  healthy  out  of  door  life  instituted,  especially 
in  connection  with  the  usual  games  of  children, 
even  if  these  are  rough.  The  great  difficulty 
with  predisposed  children  and  young  adults  is 
that  they  are  usually  carefully  shielded  from 
unpleasant  experiences  and  their  lives  made  too 
calm.  By  reason  of  such  fostering  care  any 
trivial  difficulties  to  which  they  are  unaccus- 
tomed tend  to  arouse  emotional  reactions  which 
are  out  of  proportion  to  the  exciting  cause.  In- 
stead of  being  carefully  shielded  and  kept  'Hied 
to  the  apron  strings"  of  their  mothers,  who  too 
often  are  hysteric  themselves,  children  should 
be  exposed,  carefully  at  first,  to  the  troubles  of 
childhood  and  of  maturity  and  thus  accustomed 
to  disappointments,  to  knocks^  and  to  the  neces- 
sity of  recognizing  the  rights  of  others. 

Instead  of  condoning  emotional  outbreaks 
the  child  should  be  taught  to  control  her 
temper  and  to  realize,  too,  that  desires  cannot 
always  be  indulged — ^that  many  must  be  relin- 


406  Psychopathology  of  Hysteria 

qnished.  In  fact  one  should  strive  constantly 
to  engender  emotional  stability,  and  to  discour- 
age selfislmess  and  desire  for  sympathy.  In 
place  of  making  much  ado  about  trivial  injuries 
and  thus  stimulating  desire  for  sympathy, 
parents  should  be  instructed  to  treat  these  with 
judicious  neglect,  and  never  to  sympathize  un- 
duly with  the  child  over  what  are  negligible 
and  inevitable  minor  difficulties  of  childhood. 

The  pernicious  habit  of  relating  ghost  stories 
to  children,  and  of  enforcing  obedience  with 
threats  about  the  '^  bogey  man,^'  cannot  be 
condemned  too  strongly.  Many  adults  whose 
minds  otherwise  are  not  obviously  abnormal 
are  obsessed  with  vague  fear  of  darkness,  or 
some  other  phobia  of  like  nature,  which  can  be 
traced  back  to  just  such  foolish  stories.  There 
are  few  factors  which  are  more  detrimental 
than  abnormal  fear,  and  for  this  reason  it  is  most 
essential  that  the  child  should  be  brought  up 
in  a  manner  which  is  as  devoid  as  possible  of 
elements  leading  to  the  development,  and  to  the 
encouragement  of  fear.  Rather  a  boisterous, 
noisy,  and  fearless  child  than  a  quiet  one  sub- 
dued by  various  threats  and  later  to  become 
obsessed  with  morbid  fears. 

The  practice  of  reading  trashy  literature_, 
and  especially  that  type  of  sensational  novel 
which  is  responsible  for  so  much  silly  sentimen- 
tality, is  responsible  for  the  development  of 
unhealthy  emotionalism  and  of  faulty  concep- 


Diagnosis,  Prognosis  and  Treatment    407 

tions  which  are  bound  to  lead  to  unnecessary 
disappointments  and  to  lost  illusions.  Those 
who  indulge  in  this  type  of  literature  are  the 
very  ones  who  lead  sedentary  lives,  and  con- 
sequently, the  mischievous  effects  of  such  read- 
ing  is  not  so  apt  to  be  counteracted  by  actual 
experiences.  It  is  these  young  girls  who  are 
fond  of  going  off  by  themselves  and  having  day 
dreams  in.  which  they  figure  in  unusual  and  im- 
possible episodes.  As  these  day  dreams  are 
purely  a  type  of  dissociation  in  which  imagina- 
tion is  allowed  to  run  not,  the  individual  is 
encouraging  the  development  of  unhealthy  sub- 
conscious states  which  are  characteristic  of  the 
psychoneuroses,  and  in  consequence  of  some 
emotional  disturbance  which  is  greater  than 
usual  such  states  may  assume  some  form  of 
activity  independent  of  the  consciousness  of 
what  is  now  a  patient.  The  importance  of  ro- 
mancing as  one  of  tlie  factors  in  the  genesis  of 
hysteria  cannot  be  disregarded.  One  has  only 
to  question  a  number  of  female  hysterics  to 
discover  that  the  majority  were  accustomed  to 
the  dissipation  of  day  dreaming  before  the  on- 
set of  actual  hysteria. 

As  the  shock  occasioned  by  the  first  appear- 
ance of  the  menses  in  young  girls  who,  with 
great  injustice,  have  been  kept  in  ignorance  of 
this  function,  is  often  the  exciting  cause  of  hys- 
teria it  is  most  important  that  the  phenomena  of 
menstruation  should  be  fully  explained  before 


408  Psychopathology  of  Hysteria 

pubescence  arrives.  Youths,  too,  should  be  in- 
structed concerning  the  harmless  nature  of  noc- 
turnal emissions  and  thus  saved  from  the  decid- 
edly harmful  effects  of  quack  literature  ascrib- 
ing disastrous  consequences  to  this  normal  effect 
of  sexual  continence.  The  majority  of  those 
males  who  become  what  are  commonly  designated 
sexual  neurasthenics  owe  their  distressing  con- 
dition to  inexcusable  ignorance  concerning  noc- 
turnal emissions  and  to  morbid  reproaches  for 
former  sexual  offenses.  Having  proceeded  so 
far  in  educating  the  young  in  sexual  matters  let 
us  not  stop  here.  Freud  has  shown  the  impor- 
tance of  the  sexual  instinct  in  the  genesis  of  hys- 
teria, and  clinical  experience  teaches  that  many 
females  develop  the  disease  from  occurrences 
which  could  not  have  happened  had  they  pos- 
sessed even  a  rudimentary  knowledge  of  sexual 
matters. 

Physicians  are  justified  on  these  grounds 
alone  in  encouraging  parents  judiciously  to  in- 
struct their  children  in  the  function  of  repro- 
duction. By  means  of  commencing  with  plant 
life  and  then  proceeding  to  reproduction  in  ani- 
mals this  end  may  be  accomplished  gradually, 
and  in  a  manner  which  should  be  productive  of 
nothing  but  good  results. 

The  prophylaxis  of  hysteria  is  simple  in  the- 
ory, but,  unfortunately,  the  practical  applica- 
tion of  preventive  measures  is  another  matter. 
Usually  the  physician  has  little  opportunity  of 


Diagnosis,  Prognosis  and  Treatment    409 

attempting  to  modify  or  to  prevent  the  develop- 
ment of  a  predisposition  to  hysteria,  and  his 
greatest  difficulty  is  in  contending  with  the  well 
meant  but  prejudicial  interference  of  parents. 

Treatment.  He  who  is  not  satisfied  with 
temporary  amelioration  of  symptoms  but  who 
seeks  to  ' '  cure ' '  hysteria,  or  at  least  more  or  less 
permanently  to  remove  manifestations  of  the  dis- 
ease and  to  modify  the  underlying  psychopathic 
state,  must  have  unlimited  patience,  a  large 
amount  of  time  at  his  disposal,  and  a  consid- 
erable aptitude  for  detail.  Even  though  mani- 
festations are  sometimes  capable  of  being  re- 
moved at  once  the  majority  of  patients  require 
many  hours  of  the  physician's  time  before  really 
good  results  can  be  expected.  To  be  successful 
the  physician  must  do  more  than  write  prescrip- 
tions and  give  general  advice :  he  must  plan  out 
just  how  the  patient  must  pass  every  hour  of  her 
time,  and  then  see  that  she  carries  out  his  in- 
structions. Often  he  will  be  compelled  to  find 
some  suitable  occupation  for  a  woman  who  is 
unaccustomed  to  work,  and  this.,  it  is  hardly 
necessary  to  add,  is  no  small  task.  In  view  of 
the  fact  that  to  be  beneficial  the  chosen  em- 
ployment must  interest  the  patient,  the  problem 
of  occupation  is  rendered  still  more  difficult.  As 
such  close  supervision  of  her  mode  of  living 
necessarily  renders  the  patient  dependent  upon 
the  physician  it  is  essential  that,  as  her  state 
improves,  her  self-reliance  be  developed,  and 


410  PsychopatJiology  of  Hysteria 

the  physician  must  gradually  curtail  his  at- 
tentions while  eliminating  himself  from  her 
life. 

The  treatment  of  actual  hysteria  naturally  in- 
cludes those  measures  which  are  of  value  in  the 
prophylaxis  of  the  disease.  By  reason  of  the 
psychic  nature  of  the  disease  routine  treatment 
in  the  majority  of  the  cases  must  be  attended 
with  failure.  Absolute  individualization  is  in- 
dispensable, for  measures  which  succeed  with 
one  patient  will  fail  or  even  aggravate  the 
symptoms  of  another.  Thus  one  patient  may 
recover  under  some  therapeutic  method  whose 
mainstay  is  rest,  while  others,  who  would  be 
aggravated  by  enforced  inactivity,  might  de- 
rive benefit  from  some  carefully  selected  and 
agreeable  form  of  occupation.  The  physician, 
then,  who  treats  the  patient  and  not  the  disease 
is  the  one  who  will  be  most  successful  in  his  man- 
agement of  the  psychoneuroses. 

When  examining  a  supposedly  hysteric  pa- 
tient one  should  first  eliminate  organic  disease, 
and  then  base  the  diagnosis  upon  the  psychic 
factors  of  the  case  while  carefully  avoiding  the 
production  of  any  of  the  so-called  stigmata. 
Going  into  unnecessary  detail  in  questioning  the 
patient  about  symptoms  which  might  occur  in 
hysteria,  and  too  thorough  and  repeated  study 
and  clinical  demonstration  of  symptoms  which 
have  originated  in  suggestion,  are  most  detri- 
mental.    The  more  carefully  one  examines  into 


Diagnosis,  Prognosis  and  Treatment    411 

the  state  of  the  different  kinds  of  sensibility  of 
the  patient,  and  the  more  frequently  she  is  sub- 
jected to  such  examinations,  the  more  "stig- 
mata" and  symptoms  will  be  evident  at  subse- 
quent visits,  while  the  greater  the  amount  of 
judicious  inattention  to  what  are  kno\\Ti  posi- 
tively to  be  manifestations  of  hysteria,  the  more 
rapidly  will  these  disappear. 

The  patient 's  conception  of  hysteria  is  entirely 
different  from  that  of  a  physician.  In  her  mind 
hysteria  is  not  a  disease ;  but  just  willful  display 
of  emotional  outbursts  of  crying  and  laughing 
which  occur  in  spoiled  women  who  adopt  this 
means  to  an  end.  Consequently,  having  com- 
pleted the  examination  it  is  usually  unnecessary 
and  unwise  to  tell  the  patient  that  she  has  hys- 
teria. One  should  evade  the  issue  by  calling  the 
condition  a  gastric  neurosis,  a  functional  paraly- 
sis, etc.,  until  at  least  the  patient's  confidence 
has  been  gained. 

Unless  the  physician  does  not  care  to  have  the 
patient  return  by  no  means  should  he  inform 
her,  as  so  often  is  done,  that  her  symptoms  are 
only  imaginary.  Not  only  is  this  untrue,  but  to 
her  a  splitting  headache,  a  psychic  paralysis,  an 
amblyopia,  etc.,  are  just  as  real  as  though  these 
symptoms  were  the  product  of  some  organic  dis- 
ease. Certainly,  to  be  told  that  such  distressing 
complaints  are  only  imaginary  is  most  insulting 
to  her  reason,  and  she  justly  concludes  at  once 
that  he  who  utters  such  an  assertion  neither  un- 


412  Psychopathology  of  Hysteria 

derstands  her  case  nor  Ms  own  business.  Instead, 
then,  of  making  such  a  mistake  one  should  strive 
to  arouse  the  impression  that  her  symptoms  are 
understood  perfectly,  and  that  while  none  of 
these  is  phenomenal,  or  incurable,  all  have  re- 
ceived the  same  amount  of  consideration  which 
one  would  bestow,  for  instance,  upon  a  broken 
leg. 

Naturally,  organic  disturbances  should  not 
be  overlooked,  and  when  present,  attempts 
should  be  made  to  ameliorate  or  to  correct 
them,  without,  however,  resorting  to  unneces- 
sary administration  of  drugs.  Often  the 
patient  is  informed,  with  an  unnecessary 
amount  of  solicitude,  of  relatively  harmless  ab- 
normal conditions  of  various  parts  of  her  body, 
and  the  state  of  different  organs  is  discussed 
with  an  assumption  of  profound  knowledge 
and  pseudo-scientific  thoroughness.  The  ad- 
mission of  facts  which,  because  of  their  insig- 
nificance and  in  view  of  the  abnormal  sug- 
gestibility of  the  patient,  should  be  concealed, 
or  at  least  the  inocuous  nature  of  the  abnor- 
malities carefully  explained,  may  greatly  ag- 
gravate the  condition  by  giving  additional 
cause  for  worry,  and  by  affording  the  patient 
suggestive  data  which  may  lead  at  first  to  an- 
ticipation, and  then  to  the  genesis  of  various 
new  manifestations  of  morbid  ideation.  After 
having  been  told,  for  instance,  of  a  well  com- 
pensated and  practically  harmless  mitral  re- 


Diagnosis,  Prognosis  and  Treatment    413 

gurgitation  the  patient  may  commence  to  group 
around  this  organic  nucleus  a  number  of  psy- 
chogenetic  symptoms  until  a  "cardiac  neu- 
rosis" is  developed  with  all  its  attendant  and 
distressing  symptoms.  In  fact,  the  majority  of 
cardiac  and  gastric  neuroses  can  be  traced  di- 
rectly to  the  injudicious  remarks  and  unneces- 
sary treatment  by  general  practitioners  who, 
being  satisfied  with  a  diagnosis,  either  have 
neglected  to  reassure  the  patient,  or  their 
efforts  in  this  direction  have  been  perfunctory 
and  ineffective. 

It  should  not  be  forgotten,  too,  that  as  sec- 
ondary manifestations  of  abnormal  psychic 
states  patients  frequently  present  symptoms  of 
functional  disturbance  of  the  various  organs, 
and  that  as  the  phychosis  improves  these  dis- 
turbances spontaneously  disappear.  For  in- 
stance, in  consequence  of  depressing  emotions 
the  digestive  fluids  fail  to  be  secreted  in  suffi- 
cient quantities,  with  the  result  that  fermenta- 
tion and  then  auto-intoxication  appear.  When 
having  to  deal  with  some  of  these  physical  ex- 
pressions, or  concomitants,  of  abnormal  mental 
states  judicious  neglect  often  is  desirable,  and 
local  treatment,  besides  being  frequently  inef- 
fectual, has  a  decidedly  pernicious  mental 
eff'ect. 

It  is  essential  that  the  physician  should  gain 
the  patient's  confidence;  otherwise,  all  thera- 
peutic resources  will  be  of  little  or  no  avail. 


414  Psychopathology  of  Hysteria 

The  logical  effect  of  confidence,  reinforced  by 
the  knowledge  imparted  by  the  physician  of 
the  curability  of  the  disease,  is  to  induce  the 
patient  to  anticipate  recovery  of  health.  Inas- 
much as  expectation  of  cure  usually  must  pre- 
cede amelioration  or  removal  of  symptoms,  it 
is  of  the  utmost  importance  for  the  physician 
to  strive  to  secure  this  favorable  mental  state. 
To  this  end  the  patient  should  be  assured  that 
no  matter  how  serious  her  symptoms  may  seem 
they  are  without  organic  foundation  and  they 
are  devoid  of  the  possibility  of  any  physical 
sequellffi.  Knowing  the  ease  with  which  the 
manifestations  of  hysteria  usually  can  be  dis- 
sipated one  can  affirm  honestly  that  under  the 
treatment  which  is  about  to  be  instituted  her 
symptoms  will  disappear. 

After  having  gained  the  patient's  confidence 
the  physician  might  do  well  to  explain  the 
psychic  origin  of  the  symptoms  and  the 
mechanism  of  association  of  ideas  in  the  pro- 
duction of  recurrences  of  periodic  phenomena. 
Caution  must  be  observed  in  deciding  when  it 
is  advisable  to  enter  into  such  explanations. 
Unless  one  has  sufficient  authority  to  command 
respect,  or  unless  the  patient  has  perfect  con- 
fidence in  her  physician,  she  may  become  in- 
dignant at  the  attempt  to  insinuate,  as  she 
might  express  it,  that  her  grave  symptoms  are 
only  imaginary. 

When  the  symptom  complex  includes  symp- 


Diagnosis,  Prognosis  and  Treatment     415 

toms  which  comprise  what  is  called  a  cardiac 
neurosis  the  patient  should  be  assured,  after 
careful  examination,  of  the  really  harmless 
nature  of  her  heart  lesion,  if  she  has  one.  She 
can  be  told  that  the  majority  of  people  has 
some  minor  heart  murmur,  and  that  although 
the  term  valvular  heart  disease  popularly  im- 
plies a  dangerous  malady,  this  mterpretation 
is  false.  In  reply  to  her  protest  that  she  gets 
out  of  breath  if  she  runs  up  several  flights  of 
stairs  one  has  only  to  explain  that  this  is  not 
at  all  unnatural,  and  that  among  the  normal 
expressions  of  fear  are  palpitation,  rapid  action 
of  the  heart,  and  increased  respiratory  rate. 
Consequently,  that  when  she  becomes  fright- 
ened about  her  heart,  or  at  any  time  when  she 
is  alarmed,  it  is  inevitable  that  she  should  ex- 
perience some  cardiac  and  respiratory  symp- 
toms ;  that  it  is  only  by  attending  to  these  man- 
ifestations and  fearing  gTave  consequences,  by 
reason  of  ignorance  of  their  meaning,  that  she 
aggravates  what  otherwise  are  normal  con- 
ditions. 

In  explanation  of  a  gastric  neurosis  the  pa- 
tient can  be  informed  of  the  effects  of  mental 
states  upon  the  secretion  of  digestive  fluids  as 
demonstrated  experimentally  by  Pawlow.  In 
the  same  manner  she  can  be  shown  that,  in  view 
of  the  circumstances  under  which  she  labors, 
many  of  her  symptoms  represent  normal  reac- 
tions of  the  organism,  and  that  as  her  compre- 


416  Psychopathology  of  Hysteria 

hension  of  the  physiology  of  her  body  pro- 
gresses these  circumstances  will  be  so  altered 
that  the  manifestations  no  longer  can  occur. 

Having  explained  the  symptoms  and  reas- 
sured the  patient  often  it  is  wise,  during  sub- 
sequent visits,  to  treat  with  judicious  neg- 
lect the  various  manifestations;  otherwise,  by 
keeping  the  patient's  attention  directed  upon 
them  they  are  apt  to  become  more  fixed.  For 
the  same  reason  patients  should  be  told  never 
to  talk  about  their  ill  health,  or  other  troubles, 
and  always  to  discourage  others  from  doing  so. 
It  is  well  to  instruct  her  that  when  anyone  in- 
quires about  the  state  of  her  health  she  is  to 
reply  that  she  never  felt  better,  and  then  she 
must  change  the  subject.  In  fact,  one  of  the 
difficulties  with  which  physicians  have  to  con- 
tend is  the  decidedly  mischievous,  but  well 
meant,  commiseration  of  friends  and  rela- 
tives who  are  constantly  reminding  the  patient 
of  her  manifestations.  It  is  largely  on  this  ac- 
count that  isolation  from  friends  and  relatives 
is  such  an  important  therapeutic  factor. 

Having  secured  the  patient's  confidence  and 
active  assistance,  and  having  induced  a  state  of 
expectant  attention,  the  battle  is  already  half 
won.  Almost  of  equal  importance,  however,  is 
the  understanding  with  members  of  the  family, 
if  the  patient  is  treated  at  home,  that  the  physi- 
cian's authority  is  to  be  absolute;  that  if  the 
patient  protests  about  her  inability  to  continue 


Diagnosis,  Prognosis  and  Treatment    417 

Avitli  some  therapeutic  method  -which  she  be- 
lieves will  aggravate  her  condition  they  will 
discourage  promptly  such  ideas  and  refrain 
from  interfering  with  the  management  of  the 
case.  The  importance  of  such  an  understand- 
ing is  gi-eat.  for  if  the  active  assistance  of  the 
parents  is  not  gained  in  this  respect  then  the 
physician  not  only  has  to  contend  wdth  the  pa- 
tient but  also  vrith  the  whole  family. 

When  the  patient  is  told  that  she  is  to  take  a 
daily  walk,  for  instance,  she  complains  to  her 
parents,  or  husband,  about  the  impossibility  of 
even  attempting  to  do  what  formerly  she  was 
utterly  incapable  of  doing.  They  agree  vnth 
her  and  promptly  the  physician  is  notified  that 
it  is  out  of  the  question  for  so-and-so  to  carry 
out  these  particular  directions.  Naturally,  this 
not  only  has  a  bad  suggestive  effect  upon  the 
patient,  but  it  materially  increases  the  difficulty 
in  enforcing  instructions  which  must  be  carried 
out  or  the  physician  will  lose  what  authority  he 
has  already  gained.  For  the  same  reason  no 
measure  should  be  proposed  unless  the  physi- 
cian is  reasonably  certain  that  it  can  be  suc- 
cessfully carried  out,  and  then,  having  pro- 
posed it,  it  is  necessary  that  it  shall  be  suc- 
cessfully instituted.  In  case  the  patient  re- 
mains at  home  it  is  often  just  as  necessary  to 
''treat"  the  family  as  it  is  the  patient,  and  one 
must  always  pay  much  attention  to  the  instruc- 
tion of  those  with  whom  the  patient  associates 


418  Psychopathology  of  Hysteria 

in  order  that  they  will  not  sympathize  with  her. 

Before  committing  oneself  to  any  form  of 
special  treatment  it  is  best  to  ascertain  what 
methods  have  already  been  employed.  Ordin- 
arily one  would  not  care  to  adopt  any  therapeu- 
tic measures  which  have  been  unsuccessful  in 
the  hands  of  others,  and  to  a  certain  extent  one 
would  do  well  intelligently  to  use  those  agents 
which  the  patient  regards  with  favor,  for  the 
reason  that  these  would  be  more  apt  to  arouse 
expectation  of  propitious  results. 

When  effectual,  the  so-called  rest  cure  owes 
its  success  principally  to  isolation  of  the  patient 
from  his  sympathetic  friends  and  relatives,  to 
careful  supervision  of  nutrition,  and,  in  fact, 
the  whole  daily  life  of  the  individual,  and  in  a 
large  measure  to  the  great  impression  which  the 
whole  makes  upon  the  patient,  thus  tending  to 
arouse  a  hopeful  state  of  mind.  Furthermore, 
when  members  of  the  patient's  family  also  are 
nervous,  as  so  frequently  is  the  case,  the  rest 
cure,  as  well  as  any  other  therapeutic  method 
which  includes  isolation,  withdraws  the  patient 
from  an  environment  of  unfavorable  psychic 
contagion.  The  recoveries  which  are  secured 
by  means  of  the  rest  cure  are  in  direct  propor- 
tion to  the  intelligent  manner  and  thorough- 
ness with  which  the  technique  is  carried  out. 
Even  more  important,  however,  is  the  person- 
ality of  both  physician  and  nurse. 


Diagnosis,  Prognosis  and  Treatment    419 

Tliough  good  results  are  often  obtained  with 
the  rest  cure  absolute  failure  is  not  uncommon ; 
the  patient's  condition  at  the  termination  of 
the  treatment  being  far  worse  than  before. 
This  disposition  is  greatly  increased  by  poor 
technique,  and  the  aggravation  is  due  to  the 
invalidism  which  failure  of  this  method  is  par- 
ticularly apt  to  occasion.  Furthermore,  the 
rest  cure  has  such  a  reputation  that  if  it  fails 
the  patient  naturally  infers  that  her  disease  is 
incurable,  and  her  conviction  that  such  is  the 
case  goes  a  great  way  towards  increasing  the 
resistance  of  the  disease  to  treatment. 

Often  complaints  of  fatigue  are  uttered  by 
hysteric  patients  whose  manner  of  living  is 
such  that  ordinarily  fatigue  would  not  be  ex- 
pected. If  a  patient  is  weary  because  she  can- 
not find  any  object  interesting  enough  to  hold 
her  attention,  then  assisting  her  in  finding  some 
employment  which  will  engage  her  attention, 
and,  therefore,  which  will  distract  it  from 
herself,  seems  far  more  rational  than  putting 
her  at  rest  in  bed  for  at  least  several  weeks. 
If  the  fatigue  is  expressed  as  one  which  is  phy- 
sical, the  same  method  is  applicable  because 
this  exhaustion  is  only  the  projection  of  ennui. 
If  a  woman  becomes  tired  of  the  routine  of  her 
domestic  cares,  and  if  she  cannot  anticipate 
with  pleasure  the  minor  difficulties  which  she 
must  face  and  overcome,  then  she  may  feel 
physically  exhausted  to  the  extent  that  she  be- 


420  PsycJiopathology  of  Hysteria 

lieves  herself  unable  longer  to  attend  to  her 
household  duties. 

Besides  distracting  the  patient's  attention 
from  herself  the  work  cure  has  the  additional 
advantage  of  promoting  actual  and  normal 
physical  fatigue  with  its  tendency  to  insure 
more  profound  sleep.  Exercise  in  the  open 
air  also  is  beneficial,  but  whatever  method  one 
adopts  as  a  means  of  breaking  up  sedentary 
habits,  of  distracting  the  patient's  attention, 
and  of  securing  the  benefits  of  muscular  activ- 
ity, it  is  necessary  to  interest  the  patient  in  the 
method  or  this  special  treatment  not  only  will 
be  fruitless  but  it  may  aggravate  the  condition. 
After  the  first  experience  with  physical  exer- 
cise, or  manual  training,  the  patient  is  very  apt 
to  rebel  in  consequence  of  the  unaccustomed 
actual  fatigue  which  has  been  induced.  This 
difficulty  can  be  easily  overcome,  however,  with 
a  few  words  of  explanation  and  reassurance. 

''A  form  of  treatment,"  as  I  have  written 
elsewhere,  ''upon  which  reliance  can  be  placed, 
even  in  the  most  intractable  cases  of  psychas- 
thenia,  is  a  course  of  private  instruction  in 
tumbling  and  general  gymnastic  work  under 
a  physical  director  who  is  especially  fitted  for 
the  handling  of  neurotic  patients.  Such  a  man 
is  one  who  treats  his  pupils  in  the  same  manner 
as  an  officer  would  treat  a  private  soldier ;  one 
who  n(5t  only  will  not  listen  to  remonstrances 
from  the  patient  but  who  will  not  allow  such 


Diagnosis,  Prognosis  and  Treatment    421 

to  be  made ;  who  by  the  very  strenuousness  of 
his  methods  forces  the  patient  to  concentrate 
his  attention  upon  a  diversity  of  exercises  and 
tumbling  which  he  is  expected  to  do  immedi- 
ately upon  command  and  without  protest.  In 
this  manner,  not  only  does  the  patient  receive 
the  direct  benefit  of  physical  exercise,  but  he 
acquires  self-confidence,  learns  how  to  ignore 
his  obsessions,  and  his  ego-centricity  becomes 
diminished  by  reason  of  subjecting  himself  to 
the  will  of  another."  (Jour,  of  Abnormal  Psy- 
chology, vol.  5,  p.  1.) 

Providing  that  the  patient  can  be  sufficiently 
interested  to  carry  out  the  measures  in  a  whole- 
hearted manner  any  therapeutic  method  which 
tends  to  divert  her  attention  from  herself  there- 
fore should  be  beneficial.  Accordingly,  a  re- 
stricted form  of  social  intercourse  should  be 
encouraged;  but  only  with  optimistic  friends 
who  will  not  be  solicitous  about  the  state  of  the 
patient's  health,  and  who  can  be  depended  upon 
to  discourage  unwholesome  topics  of  conver- 
sation. 

Psychic  re-education  comprises  any  explana- 
tory and  instructive  means  which  have  as  their 
aim  the  education  of  the  patient  physically  to 
react  in  a  normal  manner  to  any  stimulus. 
Naturally  these  measures  include  efforts  to 
awaken  control  of  the  emotions  so  that  they 
and  their  physical  concomitants  do  not  tend  to 
occur  to  an  extent  which  is  out  of  proportion 


422  Psychopathology  of  Hysteria 

to  the  end  to  which  they  should  be  normal  de- 
fensive reactions.  Unless  the  patient  acquires 
emotional  stability  recurrence  of  former  symp- 
toms, or  the  development  of  new  ones,  is  to  be 
expected.  Too  often  physicians  are  satisfied 
with  the  removal  of  gross  physical  manifesta- 
tions of  hysteria,  and  in  their  pleasure  over 
'^curing"  some  distressing  condition  they  over- 
look the  important  fact  that  it  is  only  a  symp- 
tom which  has  been  removed,  and  that 
the  underlying  psychopathic  state  has  not  heen 
altered.  Consequently,  it  should  not  be  a  source 
of  surprise  that  the  patient  returns,  perhaps 
in  a  few  weeks,  to  be  treated  for  some  fresh 
"accident"  or  recurrence  of  original  ones. 

Even  if  one  is  not  inclined  to  accept  the 
whole  of  Dubois'  views  concerning  the  psy- 
choneuroses  and  their  treatment  the  results 
which  he  has  obtained  are  momentous  in  that 
they  exemplify  the  enormous  possibilities  of 
psychic  re-education  associated  with  the  more 
or  less  unconscious,  but  nevertheless  positive, 
suggestive  therapeutics  which  he  denounces. 

With  suitable  cases  one  can  institute  a 
course  of  reading  which  includes  books  that 
tend  to  impress  the  patient  with  her  true  rela- 
tions with  the  outside  world;  ones  which 
should  decrease  her  ego-centricity,  and  which 
promote  philosophical  acceptance  of  the  many 
inevitable  disappointments  which  all  must 
sustain.    To  this  end  one  may  recommend  such 


Diagnosis,  Prognosis  and  Treatment    423 

books  as:  '^The  Meditations"  of  Marcus 
Aurelius;  the  ''Morals"  of  Seneca;  the  "Dis- 
courses" of  Epictetus;  Sir  John  Lubbock's 
*' Pleasures  of  Life;"  Helen  Keller's  "Optim- 
ism, ' '  and  many  others  of  like  nature. 

Li  our  efforts  to  dissipate  individual  symp- 
toms electricity  is  valuable.  Not  only  is  it, 
per  se,  a  powerful  suggestive  agent,  but  it  is  a 
most  efficient  means  of  disguising  suggestions 
which  otherwise,  being  too  obvious,  would 
surely  arouse  the  opposition  that  suggestion 
usually  evokes  when  it  is  recognized  as  such. 
No  one  will  deny  that  the  various  kinds  of  elec- 
tricity, particularly  the  impressive  high  fre- 
quency and  static  breeze  treatments,  are 
capable  of  acting  in  a  powerful  manner  upon 
the  mind  of  the  patient.  Except  by  reason  of 
its  psychic  effect,  however,  it  is  difficult  to  un- 
derstand how  electro-therapy  can  act  benefi- 
cially upon  a  group  of  physical  manifestations 
which  are  exclusively  dependent  upon  path- 
ologic mental  states. 

As  with  many  other  therapeutic  agents  the 
patient  not  uncommonly  returns  with  the  com- 
plaint that  the  first  electrical  treatment  pro- 
duced decided  aggravation  of  her  symptoms, 
or  even  that  it  originated  some  new,  and  per- 
haps extraordinary,  phenomena.  In  order  to 
attempt  to  avoid  this  event  the  harmless 
nature  of  what  she  is  about  to  undergo  must 
be  affirmed,  and  constantly  during  the  course 


424  Psychopathology  of  Hysteria 

of  the  treatment  she  must  be  reassured.  Then, 
in  case  aggravation  does  occur,  we  can  explain 
that  it  was  merely  due  to  the  natural  excite- 
ment attending  the  first  treatment  with  such 
an  awe  inspiring  agent,  and  that  subsequent 
treatments  will  be  followed  only  by  salutary 
effects.  Having  dissipated  her  fears,  or  even 
without  our  attempts  having  been  completely 
successful,  it  is  absolutely  necessary  that  the 
same  treatment  should  be  repeated;  for  no 
matter  whether  it  was  electricity  or  any  other 
agent  that  was  followed  by  aggravation,  if  the 
physician  yields  to  the  patient's  remonstrances 
he  loses  all  control  and  further  efforts  to  benefit 
her  may  be  unavailing. 

As  patients  generally  expect  to  receive 
medicine  some  harmless  remedy  may  be  pre- 
scribed solely  for  its  psychic  effect  except  when 
some  associated  malady  necessitates  active 
treatment.  Providing  that  there  are  no  posi- 
tive indications  for  medicine  the  physician 
would  do  well  to  refrain  from  giving  any  to 
those  who  are  disgusted  with  the  unnecessary 
and  fruitless  drugging  to  which  they  have 
already  been  subjected — and  there  are  many 
such.  Beside  usually  being  without  justifica- 
tion, routine  administration  of  bromides, 
strychnine  and  other  active  drugs  may  be  de- 
cidedly harmful.  Naturally  bromides  are  in- 
dicated for  the  basic  malady  of  a  case  in 
which  symptoms  of  hysteria  are  superimposed 


Diagnosis,  Prognosis  and  Treatment     425 

upon  epilepsy,  but  in  the  absence  of  this  par- 
ticular association  of  diseases  bromides  are 
worthless  in  the  treatment  of  hysteria.  Fur- 
thermore, bromides  have  a  pernicious  effect 
upon  hysterics  in  that  by  reason  of  their  seda- 
tive or  stupefying  effects  they  favor  the  produc- 
tion of  dreamy  or  hypnoid  states. 

Concerning  the  symptom  insomnia,  it  is  best 
not  to  allow  the  patient  to  gain  the  impression 
that  she  is  taking  any  medicinal  agent  to  favor 
the  production  of  sleep.  If  some  inert  prepara- 
tion is  given  in  order  to  satisfy  her  protests, 
and  if  the  character  of  sleep  improves  by  reason 
of  the  psychic  effects  of  the  supposed  hypnotic, 
then  the  patient  learns  to  depend  upon  outside 
assistance  for  the  production  of  a  state  which 
should  occur  spontaneously.  On  the  other  hand, 
if  the  remedy  really  is  a  sedative  a  true  drug 
habit  is  almost  sure  to  be  the  outcome.  To 
control  insomnia  let  us  avail  ourselves  of  psy- 
chotherapy and  of  physical  measures  which  in- 
duce actual  fatigue. 

As  all  the  symptoms  of  hysteria  are  mental 
in  origin  it  must  be  conceded  that  whether  we 
employ  drugs,  electricity,  rest  cures,  work 
cures,  or  undisguised  psychotherapy,  which  is 
in  reality  the  sine  qua  non  of  success  with  any 
form  of  treatment,  the  disease  can  be  treated 
successfully  only  with  methods  which  act 
through  the  mind  of  the  patient.  In  fact  one 
may  say  that  most  of  the  methods  of  treatment 


426  Psychopathology  of  Hysteria 

of  hysteria  succeed  only  by  reason  of  the  skilful 
application  of  suggestion  which  they  imply, 
and  that  .-with  but  few  exceptions  any  system 
of  therapeusis  which  is  not  based  upon  psycho- 
therapy— including  psychic  re-education — must 
be  of  little  value  when  applied  to  the  treatment 
of  any  of  the  psychoneuroses. 

Some  physicians  assert  that  notwithstanding 
the  fact  that  they  have  never  made  use  of  sug- 
gestion still  they  have  been  quite  successful  in 
their  treatment  of  hysteria.  They  fail  to  con- 
sider, however,  the  more  or  less  unconscious 
suggestion  which  enters  largely  into  the  rela- 
tions between  physician  and  patient,  and  their 
success  may  depend  almost  entirely  upon  the 
use  of  what  to  them  is  unconscious  suggestion 
and  rational  psychic  re-education.  This  fact  is 
amply  demonstrated  by  the  failures  of  other 
physicians  who  employ  the  same  drugs  and 
other  measures  but  whose  personalities  are  such 
that  they  cannot  command  the  patient's  con- 
fidence, and  they  are  unable  to  arouse  a  favor- 
able state  of  expectant  attention. 

As  suggestion  is  such  an  important  factor  in 
the  production  of  the  accidents  of  hysteria  the 
logical  mode  of  treatment  is  that  in  which  this 
symptomatic  exaggerated  suggestibility  is  em- 
ployed for  the  removal  of  manifestations  for 
which  it  is  responsible.  In  hysteria  dissociation 
of  personality  is  accompanied  by  increased  sug- 
gestibility which,  in  turn,  is  the  cause  of  many 


Diagnosis,  Prognosis  and  Treatment     427 

phenomena  of  tlie  disease.  Therapeutic  use  of 
suggestion  tends  to  remove  these  manifesta- 
tions and  to  effect  a  cure  by  bringing  about 
synthesis  of  the  dissociated  elements. 

In  a  bacterial  disease  the  microbes  elaborate 
a  toxin  which  reacts  upon  the  organism  to  pro- 
duce degeneration  of  the  tissues  and  symptoms 
of  toxsemia.  Graduated  application  of  auto- 
genous vaccines  not  onh^  leads  to  disappearance 
of  the  symptoms  but  also  to  cure  of  the  disease 
and  immunization  of  the  patient.  In  reply, 
therefore,  to  the  contention  that  by  means  of 
an  artificially  induced  hysteric  state  we  pre- 
sume to  cure  hysteria  one  has  only  to  refer  to 
the  successful  application  of  the  same  mechan- 
ism in  what  is  known  as  vaccine  therapy. 

Besides  psj^chic  re-education  and  the  analytic 
method  of  Freud  the  psychotherapeutic  meth- 
ods employed  for  the  removal  of  various 
sjrmptoms  consist  in  suppression,  substitution, 
and  revelation. 

With  or  without  the  induction  of  what  is 
commonly  known  as  the  hypnotic  state  a  sj^mp- 
tom  may  often  be  suppressed  by  means  of  sug- 
gestion alone,  but  in  itself  this  does  not  con- 
stitute cure  of  the  disease.  Briefly,  the  result 
is  obtained  merely  by  affirming  that  the  mani- 
festation has  disappeared,  or  ^vill  disappear 
shortly,  and  if  the  patient  has  sufficient  con- 
fidence in  the  physician,  or  if  the  physician  has 
sufficient  command  of  the  patient  to  enable  him 


428  Psychopathology  of  Hysteria   . 

to  override  her  passive  resistance,  the  symptom 
vanishes. 

The  method  of  substitution,  originated  by 
Janet,  consists  in  reproduction  during  hypnosis 
of  the  pathogenic  memory  complex,  and  then 
substitution  of  a  different  series  of  associated 
ideas  and  a  different  outcome.  For  instance, 
when  recurrences  of  crises  are  due  to  path- 
ologic association  of  ideas  consequent  upon  a 
certain  kind  of  stimulus,  and  each  crisis  is  a 
repetition  of  the  reaction  to  some  former  mental 
stress,  then  in  place  of  the  former  complex 
the  physician  substitutes  a  pleasant  series  of 
ideas  to  be  aroused  by  whatever  acts  as  the 
hysterogenic  stimulus. 

The  method  of  revelation,  a  form  of  psychic 
re-education,  depends  upon  demonstration  to 
the  patient  of  the  psychic  nature  of  the  symp- 
toms in  the  hope  that  this  will  suffice  to  cause 
them  to  disappear.  Thus,  in  case  of  monocular 
amaurosis  the  optical  inconsistencies  of  the  re- 
sults of  tests  can  be  adduced  in  order  to  con- 
vince the  patient  that  she  really  sees  with  her 
blind  eye. 

As  the  manifestations  of  hysteria  are  de- 
pendent upon  dissociated  or  submerged  com- 
plexes a  patient  really  is  not  cured  until  we 
have  effected  synthesis  with  consciousness  of 
what  has  been  pathologically  dissociated.  This 
limitation  becomes  more  obvious  in  connection 
with    the    most    highly     developed    type    of 


Diagnosis,  Prognosis  and  Treatment     42^ 

hysteria — multiple  personality.  No  matter  how 
perfect  the  results  of  treatment  of  a  case  of 
dual  personality  may  seem  surely  the  person- 
ality which  we  have  secured  is  not  what  might 
be  termed  normal  unless  the  patient  is  capable 
of  remembering  what  occurred  during  periods 
of  the  secondary  state.  Consequently,  it  is  of 
the  utmost  importance  that  the  cause  of  each 
manifestation  be  discovered,  for  no  matter  how 
bizarre  they  may  seem  each  originated  from 
some  unpleasant  experience  whose  nature 
must  be  ascertained  before  treatment  can  be 
instituted  in  an  intelligent  manner. 

The  most  logical  and  effective  form  of 
therapeusis  includes  the  discovery,  by  means 
of  some  psycho-analytic  method,  of  the  causal 
submerged  complexes;  sjoithesis  of  these  with 
consciousness;  and,  through  the  agency  of 
psychic  re-education,  the  removal  of  psycho- 
pathic tendencies. 


INDEX 


Absent      mindedness,      in- 
stance of  normal,   99 

Achiria,    78 

Achromatopsia,  112 

Aerophagia,   154 

Age  incidence  of  hysteria, 
34 

Ageusia,  133 

Alimentary      disturbances, 
144 

Allochiria,   78 

Amaurosis,   89 
Etiology  of,  90 
Character  of,  96 
Systematized,  99 
Diagnosis     of     binocular 

amaurosis,  102 
Diagnosis    of    monocular 

amaurosis,  104 
Treatm.ent,   110 

Amblyopia,    89 

Ambulatory      automatism, 
292 

Amnesia,  252,  332 
Systematized,  341 

Amselle  quoted,  114 

Anaesthesia,  56 
Etiology  of,  56 
Character  of,  65 
Interpretation  of,  74 

Angell's    case    of    subcon- 
scious fabrication,  376 

Angioneurotic  oedema,  167 

Ankle  clonus,  184 

Anorexia,  146,  315 

Anosmia,    133 

Anuria,  160 

Appetite,   156 

Aphasia,  systematized,  341 

Appendicitis,  pseudo,  157 

Argyll-Eobertson  pupil,  205 


Association   of   ideas,   150, 

240,  246,   248,  251,  255, 

270,  299 
Association    reaction    time 

experiments,  351 
Astasia-abasia,  192 
Asthma,   141 
Ataxia,  static,  83 
Attention,   94,   361 

Distraction  of,  96,  334 

Expectant,  140,  191,  208, 
246,  365 

Interference  of,  94,  125, 
178,  363 
Aura,  247 
Automatic  writing,  58,  72, 

348 
Automatism,    16 

Ambulatory,  292 

Motor,  151 


B,   Madame,   Case   of,   324 
Bachman  case,  379 
Bamberger's  case  of  fever^ 

171 
Beauchamp  case,  100,  270, 

325,  349 
Bernheim    quoted,    57,    62, 

262,   264 

Method  of   diagnosis   of 
psycholepsy,  260 

Method  of  treatment  of 
psycholepsy,  264 
Binet  's    experiments    with 

angesthesia,  72 

Test  for  amblyopia,  103 
Blindness,  see  amaurosis 
Bordley  on  the  color  fields, 

123 
Bourne,  Ansel,  case,  304 
Briquet  attacks,  224 


431 


432  Psychopathology    of   Hysteria 


C 

Cannon,  W.  B.,  quoted,  145 
Cardiac  neuroses,  165,  256 
Carpenter  quoted,   150 
Catalepsy,  272 
Charcot's  experiments  with 

dyschromatoi^sia,  113 

Conception  of  crises,  212 
Children,   normal  suggesti- 
bility of,  46,  368 
Chorea,  rhythmical,  209 
Circulatory  phenomena,  165 
Clonus,  ankle,  184 
Colitis,    entero,    mucomem- 

branous,  158 
Color    fields,    inversion    of, 

123 
Complemental      opposition, 

186 
Concentric    contraction    of 

the  visual  fields,  114 
Contagion,  psychic,  46,  216., 

225,  231 
Contractures,  199 
Convulsions,  212 

Epidemic,  53 
Core's    case    of    catalepsy, 

272 
Courtney,  J.  W.,  quoted,  311 
Crises,  212 
Curschmann  's       case       of 

hyperhydrosis,  168 
Cushing  on  the  color  fields, 

123 

D 

Darwin,  quoted,  233 
Davenport,  quoted,  53 
Deafness,    125 

Systematized,  132 
Deaf-mutism,  130 
Death  from  hysteria,  146 
Definition  of  hysteria,  29 
Delirium,   236,  349 
Delusions,   373 

Toxic,  43 


Dendritic  retraction,  theory 

of,  384 

Dercum,  C.  T.,  quoted,  165 

Diagnosis,  394 

Digestion,  Pawlow  's  experi- 
ments on,  144,  245 

Diplopia,   monocular,   206 

Dissociation  of  personality, 
19,  312 

Dreaming,  day,  356,  407 

Dreams,     spontaneous     re- 
covery     of      submerged 
memories  during,  18 
As  a  cause  of  symptoms, 

196 
Significance  of,  390 

Dynamometric       examina- 
tions,   178,   182 

Dysehiria,  78 

Dyschromatopsia,  111 

Dyspepsia,  emotional,  145 

E 

Ecstasy,  273 
Egocentricity,  359 
Elizabeth  M.,  226 
Emma  F.,  209 
Emotional  crises,  219 

Dyspepsia,   145 

Instability,  355 

Eeactions,   92,   194,   231, 
239,  387 

Eeaction,  effects  of  sup- 
pression of,  239,  388 
Epidemic  convulsions,  53 
Epidemic  hysteria,  49,  231 
Epilepsy,  pseudo  focal,  218 

Hystero,  212 

Simulated    by    hysteria, 
218,  221 
Etiology,  31 

Heredity,   31 

Environment,  33 

Faulty  education,  33 

Age,   34 

Sex,  34 

Social  factors,  36 


Index 


433 


Occupation,  37 

Eace,  38 

Climate,  38 

Acute  psychic  insults,  39 

Toxasniia,  42 

Psychic  contagion,  46 

Spiritualism,  48 

Epidemic  hysteria,  49 
Examinations        interfered 

with    by    attention,    94, 

125,  178,  363 
Expectant     attention,     see 

attention 
Eye,  disorders  of  the,   203 

F 

FabricatioD,     subconscious, 

373 
Fales,  Louis  H.,  quoted,  39 
Falsification     of     memory, 

374 
Fasting,  146 
Fatigue,  419 
Fever,   170 
Flaubert,  Gustave,  case  of, 

249 
Flees  test  of  amaurosis,  108 
Florence  K.,  case  of,  199 
Focaehon  's       experiments, 

169 
Free  will,  16 
Freud  quoted,  264,  387 

Analytic  method  of,  344 

Theories  of,  386 
Fugues,  292 

G 

Galton       whistle,       experi- 
ments with,  127 

Gangrene,  168 

Gastro-intestinal     derange- 
ments, 136 

Gastric  neuroses,  145 
Hair  balls,  157 
Ulcer,  simulation  of,  152 

Genito-urinary        derange- 
ments, 159 


Gowers,  quoted,  47 
Gradle  quoted,  96,  308 
Gustatory  disturbances,  133 
Gynecologic   operations   in 
hysterics,  164 


Habit  formation,  13 
Habit  spasms,  210 
Hasmatemesis,  152 
Hsemorrhage,     spontaneous 

capillary,  166 
Hair  balls  of  the  stomach, 

157 
Hallucinations,  373 
Toxic,  43 

Systematized      negative, 
99,  102 
Hallucinatory  pain,  84 
Hammond  quoted,  18,  286 
Hanna     case     of     multiple 

personality,  318 
Hay  fever,  138 
Healy  quoted,  167 
Hearing,  tests  of,  126 
Hemiansesthesia,  57,  62 
Hemianopsia,  124 
Hemiplegia,  181,  186 
Heredity,  31,  260 
Hiccough,  138 
Hoover's  sign,  186 
Hyperaesthesia,  84 
Hyperhydrosis,  169 
Hypnoidal  state,  242,  345 
Hypnotism,      normal      sus- 
ceptibility to,  32 
Hypnotic     suggestion,     98, 
102,   104,   110,  116,   168, 
191,   200,  210,    229,  237, 
239,  244,   253,   255,  278, 
292,   298,   307,  315,  323, 
326,  338,   344,   370,  372, 
373,  375 
''Hysterics",  395 
Hystero -epilepsy,  212 
Hysterogenic  zones,  244 


4:34  Psychopathology    of   Hysteria 


nma  S.,  experiments  on, 
168,  170 

Incoordination,  82 

Insanity,  377 

Insomnia,  282 

Inversion  of  the  color 
fields,  123 

Insular  sclerosis,  simula- 
tion of,  399 

Iridoplegia,  reflex,  205 


Jacksonian  epilepsy,  pseudo, 

218 
Jacob,  Sarah,  case  of,  148 
James,     W.,     quoted,     21, 

248,  304 
Janet  quoted,  64,  216,  279 
Jastrow  quoted,  99,  391 
Jelliffe  quoted,  382 
Jones,  E.,  on  dyschiria,  77 
Jones,  E.,  quoted,  14,  223, 

336 

K 

Kampmeier  quoted,  163 
Keller,   Helen,   unconscious 

plagiarism  of,  17 
EJaapp's  case  of  deafness, 

132 
Knee  jerks,  183 
Knowledge,  acquisition  of, 

13 
Krafft-Ebing  's  experiments 

with  lima  S.,  168,  170 


M 

Mabel  A.,  case  of,  91,  130 
MacMurray  quoted,  273 
Macnish's   case   of   somno- 
lence, 276 
Macnish  quoted,  276,  284 
Malingering,   74,   108,  148, 

152,  168,  357 
Marcelline,  case  of,  315 
Mary  D.,  case  of,  133 
Mayer,     E,     E.,     case     of 
multiple  personality,  312 
McArthur  's  case  of  pleasur- 
able pain,  358 
Medicinal    treatment,    265, 

424 
Memory,     falsification     of, 
374 

Loss  of,  see  amnesia 
Memories,  dormant,  12 
Normal    dissociation    of, 

14 
Dissociated,    methods   of 
recovery  of,  342 
Menstrual        distiu'bances, 

155,  164,  236 
Meteorism,  154 
Miss  M.,  case  of,  91 
Mitchell,    J.    K.,    case    of 

mutism,  196 
Motor  automatisms,  151 
Multiple    sclerosis,    simula- 
tion of,  399 
Murder,  379 
Mutism,  130,  193 
Mydriasis,  205 


Lady  of  Nismes,  276 
Lancereaux  case  of  somno- 
lence, 275 
Lasegue's  syndrome,  76 
Lateau,  Louise,  case  of,  166 
Lizzie  B.,  case  of,  61,  120 


N 

Narcolepsy,  268 
Neuroses,  cardiac,  165,  256 

Gastric,   145 
Nismes,  Lady  of,  276 
Nocturnal     somnambulism, 

283 


Index 


435 


0 

Ocular  palsies,  203 
Oedema,  angioneurotic,  167 
Oettinger's    case    of    deaf 

mutism,  131 
Olfactory  disturbances,  133 
Operations  gynecologic,  164 
Operations  for  pseudo   or- 
ganic   disease,    instances 
of,  156.,  157,  358 
Ophthalmoplegia,  203 
Opposition      complemental, 

186 
Organic    nervous    diseases, 
differentiating    features, 
183 
Ovarian  pains,  164 

P 

Pain,   84 

Ovarian,  164 
Pleasurable,   McArthur  ^s 
case  of,  358 
Paralyses,   ocular,  203 
Paralvsis,   173 

Etiology,  173 

Character  of,  178 

Diagnosis,  181 

Systematized,  191 

Ocular,   203 
Paraplegia,   176,   180,  189, 

201 
Parinaud  's         experiments 

with       dyschromatopsia, 

111 
^Parker,  G.  M.,  quoted,  221 
Patellar  reflexes,  183 
Pawlow^s  experiments  with 

digestion,  144,  245 
Perimetric       examinations, 

115 
Personality,  the  normal,  11 

Dissociation  of,  19 

Multiple,  312 


Perversion,  sexual,  161 
Pitre's   test   of  amaurosis, 

107 
Plagiarism  unconscious,  16 
Polyopia,  206 
Polyuria,  159 
Possession,  51 
PreWsion  of  crises,  246 
Prince  's  test  of  amaurosis, 

106 
Prince     quoted,     67,     139, 

270,  348,  372 
Prognosis,  401 
Progressive     muscular     at- 
rophy, simulation  of,  189 
Prophylaxis,  404 
Pseudocyesis,  155 
Psychasthenia,     252,     370, 

337 
Psychasthenic    convulsions, 

212,  226.,  254,  262 

Anorexia,   149 

Fugue,  308 

Polyuria,  159 

Sexual  perversion,  163 

Tics,   137,  210 
Psychic  contagion,  46,  216, 

225,  231 
Psychic  epilepsy,  221,  310 
Psycholepsy,  212 

'*  Grande  hysterie",  213 

Classification  of,  217 

Statistics,   218 

Emotional  crises,  219 

''Psychic  epilepsy",  221 

Mimicking  epilepsy,   221 

Etiology,  225 

Aurae,  247 

Diagnosis,  257 

Prognosis,  261 

Treatment,  263 

Psychic  contagion  in,  246 
Psychomotor  disorders,  173 
Pupillary  phenomena,  205 


436 


PsychopatJiology    of    Hysteria 


B 

Eacial  incidence,  38 
Eaimiste's  sign,  189 
Eeaction  time  experiments, 

351 
Eeflexes,  183 
Eeflex  iridoplegia,  205 
Eegnard  's  experiments  with 

dyschromatopsia,   113 
Eeligious  hysteria,  49,  273, 

379 
Eespiratory    derangements, 

136 
Eest  cure,  418 
Eevivals,  religious,  53,  231 
Eeynold's  case  of  multiple 

personality,  320 
Ehinorrhoea,  138 
Ehythmical  choreas,  209 
Eichardson,  W.  W.,  quoted, 

380 
Eomaneing,  356,  407 

S 
Sallie  S.,  case  of,  239,  291 
Sclerosis,  multiple,  simula- 
tion of,  399 
Sexual    incidence    of    hys- 
teria, 34 

Instinct,   161 

Origin  of  hysteria,  388 

Perversion,  161 

Eepression,     effects     of, 
389 
Sidis   quoted,   45,   54,   162, 

222,   241,    319,   346,   371 
Simulation,    74,    108,    148, 

152,  168,  357 
Singultus,  138 
Sleep,  theories  of,  45 
Sleep  walking  and  talking, 

283 
Smell,  loss  of  the  sense  of, 

133 
Somnambulism,  282 

Nocturnal,  283 


Somnolence,  268 
Spasms,  habit,  210 
Spastic  f)aralysis,   188 
Speech  disturbances,  193 
Spiritualism  in  the  etiology 

of  hysteria,  48 
Stigmata,  24,  84 
' '  Stigmatics  ",  166 
Stoeber  's  test  of  amaurosis. 

107 
Suggestibility   in   hysteria, 

26,  58,  364 
Suggestion,   59 

Inversion    of    the    color 
fields,  123 
Definition  of,  371 

Suggestion,    see    also    hyp- 
notism 

Suggestive  examinations  as 
a  cause  of  symptoms,  24, 

27,  47,  59,  67,  79,  114 
Suicide,  378 
Sweating,  168 
Sympathy,  desire  for,  357 
Synchiria,   78 
Syndrome,  Lasegue's,  76 


Talking,  sleep,  283 

Taste,  loss  of  sense  of,  133 

Temperament,  354 

Theories,    382 

Tics,  137,  210 

Time,  subconscious  deter- 
mination of  the  passage 
of,  195,  294 

Toxgemia,  42 

Toxic  hallucinations,  43 

Trance  states,  268 

Traumatic  hysteria,  36,  39, 
175,  196,  199 

Treatment,  409 

Tremors,  206 

Trophic  phenomena,  165 


Index 


437 


U 
Ulcer,    gastric,    simulation 

of,  152 
Unconscious  plagiarism,  16 
Urinary  retention,  161 

Suppression,  160 

V 
Vasomotor  phenomena,  166 
Visceral  derangements,  136 
Vision,  crystal,  348 
Visual     fields,      concentric 
contraction  of,  114 
Spiral,  119 

Bordley  and  Gushing  on 
the  color  fields,  123 


Visualization,  156 
Vive,  Louis,  case  of,  322 
Volition,  363 
Vomiting,  149,  315 

W 
Walker,  W.  K.,  quoted,  12 
AValking,  sleep,  283 
"Walton's  case  of  fever,  271 
Wilson's  case  of  malinger- 
ing, 358 
Woodiuan  quoted,  378 


X.,  Mr.,  case  of,  141,  293 


/ 


/ 


DATE  DUE 

1 

f '"  r* 

^-  ^  ^  7M] 

^001 

^   ^    t^'  4,yy  1 

i<  A\/       t 

MAY  1 

2  2801 

fr^ 

-  •*»  ^    o 

Pi 

:B  1  e  i:003 

MAR  11 

2003 

Printed 
in  USA 

COLUMBIA  UNIVERSITY 


0032327862 


